Aspen Point Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Charles, Missouri.
- Location
- 2840 West Clay St, Saint Charles, Missouri 63301
- CMS Provider Number
- 265118
- Inspections on file
- 42
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Aspen Point Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility failed to accurately reconcile and document the administration and destruction of Schedule II, IV, and V controlled substances for several residents. Policies required that controlled substances be fully accounted for, with doses on usage forms matching the MAR and controlled drug records, and that staff sign both the MAR and narcotic book after administration. Instead, surveyors identified multiple cases where the DON and ADON documented destruction of narcotics on Controlled Drug Receipt/Record/Disposition forms, yet subsequent entries on the same forms showed additional removals of tablets without corresponding MAR entries and, in some cases, without active orders. Typed destruction logs often listed destruction dates and quantities that did not match the handwritten disposition forms. Nursing staff reported that when narcotic orders are changed or discontinued, nurses pull the medication and log and give them to the DON or ADON for destruction, and that floor staff do not destroy narcotics, but acknowledged that documentation errors occurred during this process.
Surveyors found that the facility exceeded the 5% medication error threshold when a CMT prepared and administered multiple medications inappropriately for a resident with GERD, depression, anemia, hypertension, heart failure, and dysphagia. The CMT selected enteric-coated aspirin instead of the ordered chewable form, used a 100 mcg cyanocobalamin tablet instead of the ordered 1000 mcg dose despite the correct strength being available, and then crushed pantoprazole DR, venlafaxine ER, enteric-coated aspirin, potassium chloride ER, and cyanocobalamin together and mixed them in pudding before administration. These actions conflicted with the physician orders, the MAR, manufacturer instructions for delayed-release, ER, and enteric-coated products, and the facility’s Medication Administration Policy, contributing to a 24% medication error rate during the observation.
Staff failed to follow infection prevention and control practices during medication administration and high-contact care. A resident’s oral medications were prepared by a CMT who placed tablets directly into a bare hand before transferring them to a medication cup, contrary to facility policy requiring prevention of contamination and avoiding bare-hand contact with medications. In a separate case, a resident with dementia, a feeding tube, incontinence, pressure ulcers, and an MRSA-positive wound had an active order and door signage for Enhanced Barrier Precautions, yet a CNA and an LPN provided incontinence care wearing only gloves and no gowns. During this care, the CNA also handled a tube of barrier cream and applied it to the resident’s skin without changing gloves after completing fecal cleanup, despite facility expectations for glove changes between dirty and clean tasks.
A resident with severe cognitive impairment was left exposed during a bed bath, with the room door open and privacy curtain not drawn. The CMT providing care engaged in hallway conversations, violating the facility's policy on maintaining resident dignity and privacy. Staff interviews confirmed the expectation to ensure privacy, which was not met in this incident.
A resident with severe cognitive and vision impairments experienced significant weight loss due to the facility's failure to implement and monitor effective nutritional interventions. Despite a good appetite, the resident's care plan did not address weight loss, and staff did not consistently assist with meals or administer prescribed supplements. The resident frequently requested food and drink, but these needs were not adequately met, leading to an 8.61% weight loss in one month.
The facility failed to follow physician orders for three residents, leading to deficiencies in care. A resident did not receive a soft palm splint or vaccinations as ordered, another had pressure ulcers improperly treated, and a third received incorrect oxygen therapy. Staff were unaware of the orders or failed to execute them properly, resulting in lapses in care.
The facility failed to provide adequate personal hygiene care for three residents, resulting in deficiencies in oral and nail care. A resident with a stroke was not assisted with oral hygiene, leading to odorous breath and a lack of oral care supplies. Another resident, dependent on staff for ADLs, had very long fingernails, while a third resident with multiple conditions had long, jagged nails with debris. Staff interviews revealed inconsistencies in following care protocols, contributing to these deficiencies.
The facility failed to offer and document pneumococcal vaccinations for three residents, as required by its policy and CDC guidelines. A resident with a history of organ transplant received PPSV 23 but had no record of further vaccinations or education. Another resident with cancer and COPD was not offered the vaccine, and there was no documentation of administration or education. A third resident received PCV13 but had no subsequent vaccinations or education documented. Interviews with staff revealed a lack of awareness and documentation regarding vaccine administration.
The facility failed to ensure call lights were within reach for two residents, both with severe cognitive impairments and vision issues. One resident, who was blind, was repeatedly observed without access to a call light, leading to unmet needs and discomfort. Another resident, also legally blind, was unable to locate the call light despite being able to use it. Staff interviews revealed a lack of adherence to the facility's policy on call light accessibility.
The facility failed to develop baseline care plans within 48 hours for two residents, leading to deficiencies in person-centered care. One resident with pressure injuries and a recent pacemaker placement had an incomplete care plan, lacking details on ADLs and dietary needs. Another resident with stroke-related paresis had a care plan that did not address transfer status or therapy needs. Staff interviews revealed a lack of adherence to the facility's policy on baseline care plans.
Several residents, all alert and oriented, reported that staff used foul and degrading language, including profanity, when responding to their needs, making them feel worthless and less than human. Despite reporting these incidents to staff, no action was taken. Interviews with an LPN and facility leadership confirmed that some staff spoke in a rough manner, particularly on evening and night shifts.
A resident with anxiety, depression, and cognitive impairment was verbally abused by a staff member who used explicit and derogatory language during care, an incident also overheard by the resident's family member. Interviews confirmed that some staff spoke roughly, and leadership acknowledged expectations for respectful communication, though they initially viewed the event as a dignity issue rather than verbal abuse.
A resident with quadriplegia suffered bilateral leg fractures due to improper handling during a mechanical lift transfer. The facility failed to maintain the lifts in good repair, leading to unsafe conditions for multiple residents. Staff interviews revealed that malfunctioning equipment was not reported, compromising resident safety.
The facility failed to provide sufficient staffing to meet residents' needs, particularly during emergencies, as evidenced by care plans requiring four staff for evacuation. Staffing records showed multiple instances of fewer than the required five staff on night shifts. Residents with significant mobility issues were at risk due to inadequate staffing, and two residents did not receive scheduled showers, causing distress and highlighting the impact of staffing shortages on care.
Two residents dependent on staff for ADLs did not receive scheduled showers, leading to emotional distress and embarrassment over poor hygiene. Despite being cognitively intact, both residents experienced significant gaps between showers, with no documentation of refusals or alternative bathing methods. Staffing shortages were cited as a reason for not completing scheduled showers, contrary to facility policy.
The facility was found deficient in maintaining cleanliness and proper food storage. Non-food contact surfaces in the kitchen were soiled, and the ice machine lacked a proper air gap. Additionally, food items were improperly stored on the floor in the emergency supply room. The Dietary Manager and Maintenance Staff were unaware of these issues.
The facility faced administrative instability with frequent changes in the nursing home administrator position, leading to inadequate oversight and supervision. Staffing shortages resulted in delayed resident care, with some residents not receiving scheduled showers and experiencing long wait times for assistance. Mechanical lifts were not properly maintained, posing safety risks during resident transfers. Additionally, the facility failed to provide adequate training for nurse aides and did not ensure residents had access to their personal funds on weekends.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as staff did not wear gowns or have PPE available. The water management program was not followed, with no testing for Legionella and no action taken for improper water temperatures. Additionally, the facility did not track infections by organism and location, nor complete required TB tests for new employees.
The facility failed to provide an effective training program for staff, lacking documentation for required training for four CNAs. The facility's assessment identified training needs, but there was no evidence these were met. Employee files lacked orientation checklists, and skills fair attendance was not documented. Interviews revealed CNAs did not receive training on mechanical lifts, and the DON lacked records to track required CNA education hours.
The facility failed to ensure communication training for nine CNAs, lacking a system to track and document training. The DON, new to the role, did not document training, assuming HR was responsible. Employee files lacked evidence of communication education, and the facility could not provide an education calendar.
The facility failed to ensure all employees received training on resident rights, as identified in their facility assessment. Four CNAs lacked documentation of completing the required training. The DON, responsible for staff education, did not document training sessions, and there was no system to track CNA education hours.
The facility did not ensure all staff completed the required QAPI process training, as identified in their assessment. Four CNAs lacked documentation of QAPI training, and the general orientation checklist did not include it. The DON, responsible for staff education, did not document training sessions and assumed Human Resources handled it, leading to incomplete training records.
The facility failed to ensure all employees completed mandatory infection control training, as identified in their facility assessment. Four CNAs lacked documentation of completing the required training, and the Director of Nursing acknowledged the absence of individual records to track CNA education. Despite having an education calendar and conducting skills fairs, some staff did not attend, leading to a deficiency in the infection prevention and control program.
The facility failed to document compliance and ethics training for seven CNAs, despite identifying it as a training need. The DON, responsible for staff education, lacked evidence of completed training and relied on Human Resources for documentation, which was not done.
The facility failed to provide an effective training program for CNAs, particularly in dementia care and abuse prevention. Four CNAs did not receive the required 12 hours of annual training, and their files lacked documentation of orientation and skills fair attendance. Interviews revealed that staff did not receive training on mechanical lifts, learning instead from each other. The DON, responsible for staff training, acknowledged the lack of training and documentation, attributing it to a misunderstanding of responsibilities.
The facility failed to ensure an effective training program for staff, lacking documentation of required behavioral health training for four CNAs. The DON, responsible for staff education, could not provide records of completed training, leading to a deficiency in compliance.
The facility failed to provide residents with access to their personal funds on weekends, affecting 37 residents. Interviews revealed that the administrator was responsible for handling funds, which were only accessible Monday through Friday. The facility's policy and admission agreement did not specify banking hours, and the administrator was unaware of the need for weekend access.
The facility failed to maintain a homelike environment, with observations of disrepair such as missing paint, gouges, and scuff marks on walls and doors, and chipped floor tiles. Residents reported long-standing requests for repairs, which were not addressed. Interviews revealed a breakdown in the maintenance reporting process, with the Maintenance Director and Administrator acknowledging lapses in repair protocols.
The facility failed to complete required PASRR screenings for four residents with mental disorders or intellectual disabilities before admission. Despite having a policy in place, the facility did not adhere to it, resulting in missing or outdated PASRR documentation. Interviews revealed confusion among staff regarding responsibilities for the PASRR process, contributing to the deficiency.
The facility failed to serve food at safe and appetizing temperatures, as evidenced by resident complaints and observations of cold meals. Food temperatures were not monitored during service, and trays were sometimes delivered without insulated covers, leading to systemic issues with maintaining appropriate temperatures.
The facility failed to keep dumpster lids closed when not in use, as observed with two open dumpsters partially filled with garbage and litter scattered on the ground. Staff interviews confirmed the expectation for lids to be closed, highlighting a lapse in adherence to this protocol.
The facility failed to maintain mechanical lifts in safe operating condition, with one lift out of service due to a dead battery and two others having sticking wheels and legs. Staff continued to use the malfunctioning lifts without reporting issues to maintenance, contrary to facility policy. Observations showed dirt buildup, rust, and operational noises, while interviews revealed staff difficulties in using the lifts.
The facility failed to report an injury of unknown origin for a resident with unexplained leg fractures and did not report an allegation of staff-to-resident verbal abuse for another resident. The facility's policies required immediate reporting of such incidents, but staff did not adhere to these procedures, resulting in deficiencies.
A facility failed to investigate an injury of unknown origin for a resident with unexplained leg fractures and did not investigate a verbal abuse allegation by another resident against a CNA. Despite policies requiring immediate investigation, the facility did not classify the injury as unknown or conduct a thorough inquiry into the abuse claim, resulting in a deficiency in handling potential abuse and injuries.
The facility failed to notify the state-designated authority for a Level II PASRR for two residents with mental disorders or intellectual disabilities. One resident was re-admitted from a psychiatric hospital without a Change in Status PASRR, and another had a Level I screening without triggering a Level II evaluation despite significant diagnoses. Staff interviews revealed confusion and lack of clarity regarding responsibility for the PASRR process.
The facility failed to provide necessary care for three residents unable to perform their own ADLs, including bathing, grooming, and hygiene. Additionally, a resident was not checked for incontinence for a prolonged period, resulting in them being wet and soiled. These issues were identified through observation, interview, and record review.
A resident with liver disease in a long-term care facility was hospitalized after staff failed to administer lactulose as ordered and did not follow up on critical lab tests. The resident became lethargic and dehydrated, with elevated ammonia and electrolyte levels. Staff interviews revealed missed medication doses and inadequate communication with the physician regarding the resident's declining condition.
The facility failed to provide adequate nursing staff to meet the needs of eight residents out of a sample of 28. Observations, interviews, and record reviews revealed that the facility did not ensure licensed staff were scheduled according to the facility's assessment. The facility had a census of 65 residents.
The facility failed to maintain a clean, safe, and comfortable environment for residents. Observations and interviews indicated that resident rooms, hallways, and common areas were not clean and free of odors, floors were littered with debris, and trash in resident rooms was not emptied. This deficiency affected a facility with 65 residents.
The facility did not administer medications to two residents within the designated time frame and failed to ensure a resident took their medication by leaving it unattended. Additionally, a controlled medication was not administered as ordered by the physician.
The facility did not provide necessary care for three residents who were unable to perform their own ADLs. These residents did not receive adequate assistance with bathing, grooming, personal hygiene, and nail care, as identified through observation, interview, and record review.
The facility did not comply with staffing requirements by allowing the DON to work as a charge nurse when the census was over 60 residents. This issue was observed on several occasions with a census of 65, and it remains uncorrected from previous reports.
A facility failed to provide necessary treatment and services for the assessment, prevention, and healing of pressure ulcers for a resident. This deficiency was identified through observation, interview, and record review among a sample of 28 residents, with a facility census of 65.
The facility failed to protect residents from misappropriation of narcotic medications by an LPN, who signed out medications but did not administer them as documented. The issue was discovered when a resident reported not receiving their pain medication, leading to an investigation that revealed multiple discrepancies in medication administration records.
The facility failed to follow proper infection control techniques during blood glucose monitoring for two residents, including one with Hepatitis C, by not using the required disinfectant wipes and not placing barriers between the glucometer and surfaces. Additionally, staff did not follow the facility's perineal care policy, using the same cloth surface multiple times and not changing gloves when soiled, compromising residents' hygiene and increasing the risk of infection.
The facility failed to ensure that residents could voice concerns without fear of retaliation and did not treat a resident with dignity and respect. Residents reported staff taking longer to respond to call lights or refusing assistance after complaints. One resident was told to stay on the floor and be quiet after falling, without being helped back into bed.
The facility failed to provide adequate care and supervision for three residents, leading to significant incidents. One resident fell out of bed during incontinence care due to improper positioning and an incorrectly set mattress, another was improperly transferred using a Hoyer lift by only one staff member, and a third resident on a pureed diet was left unsupervised with a peanut butter and jelly sandwich within reach, which they consumed without staff knowledge.
The facility failed to ensure adequate staffing, with only three staff members caring for 71 residents during a night shift. Staff reported difficulties in providing timely care, and instances of staff sleeping while on duty were observed. The facility's policy required sufficient staff to ensure resident safety, but significant staffing shortages were evident, and administration was aware but had not taken corrective actions.
Inaccurate Documentation and Reconciliation of Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to accurately reconcile and document the administration and destruction of Schedule II, IV, and V controlled substances for multiple residents, contrary to its own policies on controlled substance accountability and medication administration. Facility policy required that all controlled substances be clearly documented on designated usage forms, that doses on the usage forms match the MAR and controlled drug records, and that the controlled drug record serve as the record of both narcotic disposition and resident administration. Policy also required that staff sign the MAR after administration and sign the narcotic book for controlled substances. Surveyors found repeated instances where destruction dates and quantities recorded on Controlled Drug Receipt/Record/Disposition forms did not match typed destruction logs, and where staff documented removal of narcotics from the controlled drug record without corresponding documentation of administration on the MAR. For one resident with an order for hydrocodone/APAP 5/325 mg as needed for pain, the order was discontinued near the end of January, and there was no documentation on the January MAR that the medication had been administered. The Controlled Drug Receipt/Record/Disposition form for hydrocodone/APAP dispensed in June showed that on a January date, the ADON and DON documented destruction of three tablets, yet subsequent entries on the same form showed staff removing tablets on later January dates with no matching MAR entries. A typed destruction log later showed that 14 tablets of the same medication were destroyed via drug buster on a later January date, and this destruction amount did not match the amount documented on the disposition form. The DON acknowledged that staff should document narcotic administration on the MAR when removing medication from the count sheet and should not administer medication after an order is discontinued, and she attributed discrepancies to poor handwriting and being in a hurry. For another resident with multiple tramadol 50 mg orders that were tapered and then discontinued in December, the December MAR showed no tramadol administration after the final discontinuation date, and there was no tramadol order on the January POS or MAR. The Controlled Drug Receipt/Record/Disposition form for tramadol dispensed in early December showed that on a December date the ADON and DON documented destruction of three tablets, while the last entry that same day showed ten tablets remaining. Despite this, subsequent entries on the form documented removal of tramadol tablets on later December and January dates, none of which were documented on the MAR. A typed destruction log showed that 26 tablets were destroyed via drug buster on a December date, which did not match the destruction amount on the disposition form. The DON stated that the destruction date should have been a January date and that the 26-tablet destruction entry was an error based on the delivered quantity. For a third resident with pregabalin 50 mg ordered at bedtime and later changed to pregabalin 75 mg, the 50 mg dose was discontinued in November, and there were no MAR entries for pregabalin 50 mg after the discontinuation date in November, nor any active order for this dose on subsequent POS or MARs. The Controlled Drug Receipt/Record/Disposition form for pregabalin 50 mg dispensed in November showed that on a November date the ADON and DON documented destruction of 19 tablets. However, the same form contained later entries showing staff removing pregabalin 50 mg tablets on multiple dates in November, December, and January, with no corresponding MAR documentation and no active order for this dose. A typed destruction log showed that 19 tablets were destroyed via drug buster on the same November date. The DON later stated that the destruction date should have been a January date. For a fourth resident with an order for oxycodone hcl 5 mg as needed that was discontinued in late September and a later order for oxycodone/acetaminophen 10/325 mg twice daily, the October POS contained no order for oxycodone hcl 5 mg. The Controlled Drug Receipt/Record/Disposition form for oxycodone hcl 5 mg dispensed in August showed that on a September date the ADON and DON documented destruction of five tablets. Despite this, the same form showed entries for removal of one tablet on a September date and two tablets on an October date, with no MAR documentation for these administrations and no active order for that dose in October. A typed destruction log showed that five tablets were destroyed via drug buster on the September date. The DON stated that the destruction date should have been an October date and believed that the removal of two tablets in October reflected staff taking two tablets to administer under the then-current order. Interviews with RN A and the ADON confirmed that when narcotic orders are changed or discontinued, floor nurses pull the medication and log from the cart and give them to the DON or ADON for destruction, that floor staff do not destroy narcotics, and that the ADON’s initials in the destruction box indicate acknowledgment that the medication had been destroyed, though both acknowledged that errors may have occurred in the documentation process.
Crushing of Non-Crush Medications and Incorrect Dosing Resulting in Elevated Med Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 6 errors out of 25 opportunities, resulting in a 24% error rate. The deficiency centered on one resident with diagnoses including GERD, major depressive disorder, vitamin B12 deficiency anemia, hypertension, heart failure, and dysphagia. Physician orders and the MAR for this resident specified pantoprazole sodium delayed release 20 mg daily, venlafaxine HCl ER 24-hour 75 mg daily, chewable aspirin 81 mg daily, potassium chloride ER 20 mEq daily, and cyanocobalamin 1000 mcg daily, with no order to crush medications. During a medication pass observation, a CMT prepared the resident’s morning medications by removing pantoprazole DR 20 mg, venlafaxine ER 75 mg, potassium chloride ER 20 mEq from pharmacy cards, and aspirin 81 mg and cyanocobalamin 100 mcg from facility stock bottles. The aspirin provided was enteric-coated from stock, not chewable as ordered, and the cyanocobalamin dose selected was 100 mcg instead of the ordered 1000 mcg, despite a 1000 mcg stock bottle being available in the cart. The CMT then combined all of these medications into a plastic sleeve, crushed them, and mixed the crushed medications into a pudding cup before administering them to the resident. The facility’s own Medication Administration Policy required staff to verify medications against the MAR, administer medications as ordered, and not crush medications that are delayed-release, extended-release, or enteric-coated. Reference information from drugs.com cited in the report specified that pantoprazole DR, venlafaxine ER, enteric-coated aspirin, and potassium chloride ER must be swallowed whole and not crushed. In an interview, the CMT stated they were aware of which medications could and could not be crushed, claimed to have tried to position the aspirin so it would not be crushed, and indicated they believed the 1000 mcg cyanocobalamin dose was a mistake and therefore used the 100 mcg product instead. The DON and Administrator stated they expected staff to follow physician orders, verify doses with the MAR and medication containers, and avoid crushing enteric-coated, extended-release, or delayed-release medications.
Failure to Follow Infection Control Practices During Medication Administration and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during medication administration and resident care. For one resident, a Certified Medication Technician (CMT) prepared multiple oral medications by placing each tablet directly into his or her bare hand before transferring them into a medication cup. The medications included aspirin 81 mg, metoprolol tartrate 12.5 mg, and potassium chloride extended release 20 meq, which were scheduled on the resident’s Medication Administration Record. This practice occurred despite the facility’s Medication Administration Policy, which specifies that medications are to be administered in a manner that prevents contamination or infection and that staff should remove medications from their source without touching them with bare hands. The CMT later acknowledged awareness that medications should not be handled with bare hands and stated he or she did not realize bare hands had been used during preparation. A second deficiency concerns the facility’s failure to implement Enhanced Barrier Precautions (EBP) and appropriate glove use during high-contact care for a resident with significant infection risks. This resident had diagnoses including dysphagia, stroke, unspecified dementia, was always incontinent of bowel and bladder, had a feeding tube, was at risk for pressure ulcers, and had one or more unhealed pressure ulcers with a documented MRSA-positive wound culture from the left heel. The resident’s care plan and physician orders required EBP, including the use of gown and gloves during high-contact resident care activities such as dressing, bathing, transfers, linen changes, incontinence care, wound care, and device care for the feeding tube. A sign on the resident’s door clearly indicated EBP requirements, and gowns and other EBP supplies were available outside the room. During observed incontinence care for this resident, a CNA and an LPN entered the room and provided high-contact care while wearing gloves only and no gowns, despite the posted EBP sign and the resident’s need for EBP due to a feeding tube and chronic wounds with MRSA. The resident was incontinent of bowel and bladder, and the CNA performed perineal and incontinence care while the LPN assisted with positioning and turning. The CNA removed soiled gloves, performed hand hygiene, donned new gloves, and continued care until all feces were removed. Without changing gloves again, the CNA then picked up a tube of barrier cream from the bedside table, touched the resident’s hip, and applied the cream to the resident’s buttocks. Interviews with the CNA, LPN, Infection Preventionist, and DON confirmed that staff were aware EBP was required for this resident, that gowns and gloves should be used for high-contact care, and that gloves should be changed when moving from dirty to clean tasks and before handling barrier cream, but these practices were not followed during the observed care.
Resident Privacy and Dignity Compromised During Care
Penalty
Summary
The facility failed to ensure personal privacy and dignity for Resident #4 during a bed bath. The resident, who had severe cognitive impairment and was dependent on staff for personal hygiene, was left fully exposed in their room with the door open and privacy curtain not drawn. Certified Medication Technician (CMT) L entered the room without knocking or introducing themselves and proceeded to provide a bed bath while engaging in conversations with other residents in the hallway, further compromising the resident's privacy. Despite the facility's policy to maintain resident dignity and privacy, CMT L did not adhere to these guidelines, leaving the resident exposed throughout the care process. Interviews with staff, including the Registered Nurse and Director of Nursing, confirmed that the expected protocol was to close the door and curtain to ensure privacy. The Administrator also emphasized the importance of treating residents with dignity and respect, highlighting a clear deviation from the facility's standards in this incident.
Failure to Address Resident's Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to consistently implement, evaluate, and modify interventions to prevent unintended weight loss for a resident who experienced an 8.61% weight loss in one month. The resident, who had severe cognitive impairment and vision loss, required supervision or assistance for eating. Despite being on a regular diet with nectar thickened liquids and having a good appetite, the resident's care plan did not address weight loss or include interventions to prevent further weight loss. The resident's weight loss was documented, but the care plan was not updated to reflect this change, and interventions were not effectively implemented. Observations revealed that the resident often did not receive adequate assistance during meals, leading to incomplete consumption of meals. The resident frequently asked for food and drink, indicating hunger and thirst, but staff did not consistently respond to these requests. The resident's dietary preferences, such as a desire for peanut butter and jelly sandwiches, were not accommodated, and the resident was not provided with a menu to make meal choices due to blindness. Additionally, the resident's prescribed nutritional supplements were not consistently administered, as documented in the Medication Administration Record. Interviews with staff indicated a lack of awareness regarding the resident's frequent requests for food and drink and the resident's documented weight loss. The Registered Dietician and Director of Nursing were not informed of the resident's refusal or non-consumption of supplements, and the interdisciplinary team did not discuss the resident's weight loss in meetings. This lack of communication and failure to implement and monitor effective interventions contributed to the resident's significant weight loss and unmet nutritional needs.
Failure to Follow Physician Orders for Residents
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in care. For Resident #30, the staff did not apply a soft palm splint to the resident's contracted right hand as ordered. Despite the Therapy Director's education and placement of palm guards in the resident's room, observations over several days showed the resident without the splint, and staff were unaware of its location. Additionally, the resident did not receive the Tdap, Prevnar 20, or COVID booster vaccinations as ordered, due to a failure in the administrative process that did not generate the orders into the nurse administration record. Resident #14's care was compromised when staff did not follow orders to pack the resident's pressure ulcers with gauze. The resident had multiple stage IV pressure ulcers that required specific treatment, but LPN N only covered the wounds with a 4x4 gauze and bordered foam dressing, neglecting the packing order. The Assistant Director of Nursing confirmed the absence of packing during a treatment observation, and the Physician Assistant expressed concern that the wounds could worsen without proper care. For Resident #5, the staff did not follow the physician's order for oxygen therapy. The resident was observed receiving 4.5 liters of oxygen per minute, contrary to the order of 2 liters while in bed. CNA B, who was not authorized to adjust oxygen levels, set the concentrator incorrectly, and there was no documentation of any respiratory symptoms that would justify the increase. The DON and the resident's Physician Assistant both emphasized the importance of adhering to the prescribed oxygen levels, highlighting a significant lapse in following medical orders.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, resulting in deficiencies in personal hygiene care. Resident #102, who had a stroke and dysphagia, was observed with odorous breath and a white substance around the mouth, indicating a lack of oral hygiene care. Despite being unable to move his dominant hand and requiring assistance, the resident reported not receiving any help with oral hygiene since admission. Observations confirmed the absence of oral care supplies in the resident's room, and staff interviews revealed a lack of awareness and adherence to oral care protocols. Resident #14, who was dependent on staff for all ADLs, was found with very long fingernails, despite the care plan indicating regular nail care. The resident expressed dissatisfaction with the lack of nail trimming, and observations confirmed the neglect over multiple days. Staff interviews highlighted inconsistencies in the provision of nail care, with some staff unaware of the resident's needs or failing to perform the necessary checks during routine care. Resident #12, diagnosed with multiple conditions including stroke and schizophrenia, was observed with long, jagged fingernails containing debris. Despite being cognitively intact and requiring supervision for personal hygiene, the resident's nails were not adequately maintained. Staff interviews revealed a lack of consistent nail care checks during shower days, with some staff failing to notice the need for nail trimming. The facility's policies and staff expectations for nail and oral care were not consistently followed, leading to these deficiencies.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide evidence that it offered the pneumococcal vaccination to three residents, as observed in a review of 17 sampled residents. The facility's policy, dated 9/1/21, mandates offering pneumococcal immunization to residents, staff, and volunteers in accordance with CDC guidelines. However, the facility did not document offering the vaccine to Residents #5, #29, and #36, nor did it provide education on the benefits and potential side effects of the vaccination. Resident #5, who was over a certain age and had a history of organ and tissue transplant with rejection, received the PPSV 23 vaccine on 02/05/22. There was no documentation of any other pneumococcal vaccinations being offered or administered, and the resident's medical record lacked evidence of education regarding the vaccine. Similarly, Resident #29, diagnosed with cancer of the hypopharynx and COPD, was not offered the pneumococcal vaccine, and there was no record of the PPSV23 vaccine being administered despite it being scheduled. The resident's medical record also showed no documentation of education provided about the vaccine. Resident #36, who was over a certain age and diagnosed with adult failure to thrive, received the PCV13 vaccine on 12/12/14, but there was no documentation of any subsequent pneumococcal vaccinations being offered or administered. The resident's medical record did not include evidence of education regarding the vaccine. Interviews with facility staff, including the Corporate RN and the DON, revealed a lack of awareness and documentation regarding the administration of the pneumococcal vaccine to these residents.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents #26 and #4, had their call lights within reach, which is a violation of the facility's policy on call light accessibility and timely response. Resident #26, who was blind and had severe cognitive impairment, was observed multiple times without access to a call light. Despite the resident's repeated calls for assistance, the call light was consistently found hanging on the wall between the beds, out of reach. The resident expressed frustration about not being able to call for help and was observed in various states of discomfort and need without staff assistance. Resident #26's care plan indicated a need for the call light to be within reach due to his/her blindness and history of falls. However, observations showed that the resident was left without pants and was cold, and eventually found on the floor after attempting to lay down without assistance. Interviews with staff, including the RN, CMT, and DON, revealed a lack of awareness or adherence to the policy, as they all expected the call light to be within reach but failed to ensure it was so. Similarly, Resident #4, who also had severe cognitive impairment and was legally blind, was observed without the call light within reach. The resident's care plan required the call light to be accessible, yet it was consistently found hanging on the wall, out of reach. Despite the resident's ability to use the call light, staff interviews indicated a misunderstanding of the resident's needs, as the CNA believed the resident could use the call light, but the resident did not know its location. The DON and Administrator both stated that the call light should be within reach, highlighting a systemic issue in ensuring compliance with the facility's policy.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, leading to deficiencies in providing person-centered care. Resident #405 was admitted with multiple unstageable pressure injuries and a recent pacemaker placement. Despite having specific care needs, such as a mechanically altered diet and assistance with activities of daily living (ADLs), the resident's care plan was incomplete. It did not address the type of assistance required for ADLs, dietary needs, or the presence of pressure ulcers. The resident frequently refused care, including getting out of bed and eating, which was not adequately documented or addressed in the care plan. Resident #102 was admitted with a history of stroke, resulting in left-side paresis and requiring assistance with transfers and oral hygiene. The resident's care plan was not completed within the required timeframe and failed to address critical care needs, such as transfer status, assistance with oral care, and the use of a left arm/hand brace. The lack of a comprehensive baseline care plan meant that the resident's specific needs were not being met, potentially impacting their recovery and quality of life. Interviews with facility staff, including the Director of Nursing (DON) and Registered Nurses (RNs), revealed a lack of awareness and adherence to the facility's policy on baseline care plans. The DON admitted that the completion of a baseline care plan was expected but not included in the admission checklist, leading to oversight. The Administrator also acknowledged the expectation for baseline care plans to be completed within 48 hours, highlighting a gap between policy and practice.
Failure to Ensure Resident Dignity Due to Staff Use of Foul Language
Penalty
Summary
The facility failed to ensure that four residents were treated with respect and dignity, as required by their own policy and federal regulations. Multiple residents, all of whom were alert, oriented, and able to communicate their needs, reported that staff members used foul language, including words such as 'fuck,' 'shit,' and 'damn,' when responding to them or providing care. Residents described staff raising their voices and making degrading comments, such as 'what the fuck do you want?' These interactions made the residents feel bad, worthless, upset, ignorant, and less than human. The incidents were reported to staff by the residents, but no action was taken in response to their complaints. Interviews with staff confirmed that some employees spoke to residents in a rough manner, particularly during evening and night shifts. The DON and facility administrator acknowledged that staff are expected to treat residents with respect and dignity and not use foul language. The residents involved had diagnoses including schizophrenia, depression, and anxiety, but were able to make themselves understood and participate in decision-making. The facility census at the time was 53.
Resident Subjected to Verbal Abuse by Staff Member
Penalty
Summary
A resident with a history of anxiety, depression, moderate cognitive impairment, and delusions reported being subjected to verbal abuse by a staff member. The incident involved the staff member using explicit and derogatory language, specifically calling the resident a 'fucking bitch' and telling them to 'shut the fuck up' while providing care. The resident's family member, who was on the phone at the time, also heard the abusive language. The resident expressed feeling angry and upset as a result of the staff member's actions. Interviews with facility staff revealed that some staff members were known to speak in a rough manner. The Director of Nursing and the facility Administrator acknowledged that staff are expected to treat residents with respect and dignity and not use foul language. However, after being informed of the specific language used, they characterized the incident as a dignity issue rather than verbal abuse. Facility policies reviewed by surveyors clearly prohibit abuse, including verbal abuse, and require staff to honor residents' rights to dignity and respect.
Unsafe Resident Transfers and Equipment Malfunction
Penalty
Summary
The facility failed to safely transfer a cognitively intact resident with quadriplegia, resulting in significant injuries. During a mechanical lift transfer, two unidentified staff members did not maintain control of the resident, causing the resident's legs to hit the lift. When the resident was over the bed, the staff mistakenly hit the emergency release instead of the lowering button, causing the resident to drop onto the bed with their legs bent underneath. This incident led to the resident experiencing pain and swelling in their legs, and subsequent hospital evaluation revealed bilateral leg fractures. Additionally, the facility failed to ensure the mechanical lifts used for transferring residents were maintained in good repair. Observations showed that the wheels on the mechanical lifts did not function properly, causing staff to forcefully push the lifts, which resulted in residents swinging while suspended. This lack of maintenance and improper handling during transfers was also observed with two other residents, where staff did not maintain control during the transfer, leading to unsafe conditions. Interviews with staff revealed that some of the lifts were hard to use due to malfunctioning wheels and legs, which were not reported to maintenance. The facility had three Hoyer lifts, one of which was not working due to a battery issue, and the other two were difficult to use. Despite these issues, staff continued to use the malfunctioning equipment, compromising resident safety during transfers.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, particularly during emergencies, as evidenced by the care plans of two residents requiring four staff members for emergency evacuation. However, the facility's staffing records showed that on multiple occasions, fewer than the required five staff members were present on the night shift. This staffing shortage was noted on 19 days between July and August, with instances of only two or three staff members present, which was below the facility's identified need of five staff members for the night shift. Resident #25, who had significant mobility issues and required maximal assistance for transfers, was at risk due to the insufficient staffing levels. The resident's care plan specified the need for four staff members to safely evacuate them using a bariatric sling in an emergency. However, interviews with staff and the resident revealed that there were not always enough staff members on duty to meet this requirement. Similarly, Resident #157, who was dependent on staff for all transfers due to quadriplegia, also required four staff members for emergency evacuation, but the facility's staffing levels were inadequate to ensure this. Additionally, the facility failed to provide scheduled showers for two residents, #23 and #49, due to insufficient staffing. Resident #23, who was dependent on staff for all activities of daily living, did not receive showers as scheduled, with documentation showing significant gaps between showers. The resident expressed distress over the lack of personal hygiene care, citing long wait times for call light responses and insufficient staffing on weekends. Resident #49 also experienced missed showers, with records indicating only one shower received out of nine scheduled in July, and similar issues in August. Interviews with staff confirmed that staffing shortages impacted their ability to provide timely care and complete scheduled tasks.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide necessary care to maintain good personal hygiene for two residents who were dependent on staff for their activities of daily living (ADLs). Resident #23, who was cognitively intact but had limited range of motion in both lower extremities and was dependent on staff for all ADLs, did not receive showers as per the facility's schedule. The resident's care plan did not specify the frequency of showers, and documentation showed significant gaps between showers, with no records of refusals or alternative bathing methods offered. The resident expressed emotional distress and embarrassment over their unclean and oily hair, indicating a lack of proper hygiene care. Similarly, Resident #49, who was also cognitively intact but had limited range of motion on one side of both upper and lower extremities, required extensive assistance with ADLs. The resident's care plan also lacked details on the frequency of showers. Documentation revealed that the resident went extended periods without showers, with no records of refusals or alternative bathing methods. The resident expressed a desire for two showers per week but often received only one or none, leading to feelings of embarrassment and distress over their greasy hair. Interviews with staff, including CNAs and the DON, revealed that staffing shortages were cited as a reason for not completing scheduled showers. Staff were expected to document refusals and notify nurses, who would then speak to the resident and document any continued refusals. However, this process was not consistently followed, resulting in residents going without showers for weeks. The facility's policy required residents to receive showers twice a week, but this standard was not met, leading to the observed deficiencies.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage practices in the kitchen and emergency supply room, as observed during a survey. In the kitchen, non-food contact surfaces such as the fire drop curtain, electrical junction box, and electrical receptacle box were found to be soiled with grease, dust, and debris. The Dietary Manager acknowledged that the dietary department was responsible for cleaning these areas but was unaware of the issues. Additionally, the ice machine's drainpipe lacked the required air gap, with the pipe extending into the floor drain well, which was not known to the maintenance staff responsible for monitoring it. In the emergency supply room, food items including a bag of instant non-fat dry milk, bags of vanilla pudding and pie filling, and a box of vanilla wafers were stored directly on the floor, contrary to the facility's policy. The Dietary Manager, who monitored the room weekly, was unaware of these items being improperly stored. The Registered Dietician also expected food items to be stored off the floor, indicating a lapse in adherence to food safety requirements.
Administrative Instability and Staffing Shortages Lead to Deficiencies
Penalty
Summary
The facility experienced significant administrative instability with six changes in the licensed nursing home administrator position over a short period. This instability contributed to a lack of oversight and supervision of employees and resident care. An allegation of verbal abuse was not reported to the state agency, indicating a failure in the facility's abuse reporting protocol. Additionally, the facility did not maintain sufficient nursing staff to ensure the health and safety of residents, as evidenced by multiple shifts operating below the required staffing levels. This staffing shortage led to delays in resident care, such as prolonged wait times for call light responses and missed showers. Mechanical equipment, specifically mechanical lifts, was not maintained in a safe manner. Observations revealed that the lifts had issues such as sticking wheels and malfunctioning batteries, which were not reported or addressed by the staff. This lack of maintenance posed a risk to both residents and staff during transfers. Furthermore, the facility failed to provide adequate training for nurse aides, as ongoing in-service training was not completed, and there was no structured orientation for new hires. This lack of training likely contributed to the improper handling of equipment and resident care. Residents reported dissatisfaction with the facility's handling of their personal funds, as they were unable to access their money on weekends. The administrator was unaware of the need to provide access to resident funds on weekends, highlighting a gap in administrative knowledge and resident rights. Additionally, residents expressed frustration with the lack of timely assistance and personal care, with some residents not receiving scheduled showers for weeks. These deficiencies in staffing, equipment maintenance, and administrative oversight collectively compromised the quality of care provided to the residents.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP) as required by facility policy when providing care and treatment to residents with wounds or indwelling medical devices. Specifically, staff did not wear gowns or have personal protective equipment (PPE) available when performing high-contact care activities for residents with methicillin-resistant Staphylococcus aureus (MRSA) infections and other conditions requiring EBP. Interviews with staff, including the Infection Preventionist (IP) and Director of Nursing (DON), revealed a lack of awareness and implementation of EBP practices, with some staff unaware of the EBP program altogether. The facility also failed to implement its water management program to identify and reduce the risk of Legionella bacteria growth and spread. The maintenance director did not conduct water testing for Legionella, lacked a water flow diagram, and did not take action when water temperatures were outside the recommended range. There was no water management team or committee, and the facility did not follow guidelines for Legionella prevention, as confirmed by interviews with the maintenance director and DON. Additionally, the facility did not track infections by organism and location, nor did it complete Tuberculin Skin Tests (TST) and/or annual evaluations for new employees as required. The Infection Preventionist did not map infections or follow up on residents who completed antibiotic courses. The DON expected the IP to track infections and communicate trends, but this was not being done. The facility's infection control log lacked documentation of the organisms being treated and the locations of infections, indicating a failure in the infection prevention and control program.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to ensure an effective training program for new and existing staff, as evidenced by the lack of documentation for required training for four CNAs out of nine employees reviewed. The facility's assessment identified specific training needs, but there was no evidence that these were met. The facility's census was 54, and the training topics included communication, resident rights, abuse prevention, infection control, and emergency preparedness, among others. However, the facility did not provide documentation or evidence that these training sessions were completed by the staff members in question. The review of employee education files for CNAs O, Y, AA, and BB revealed that their files did not include a general orientation checklist or documentation of attendance at the facility's general orientation. Additionally, their education records did not show a minimum of 12 hours of training or competencies identified in the facility assessment. The skills fair attendance lists did not include signatures from these CNAs, indicating they did not attend the required training sessions. Interviews with staff members, including CNAs and the Director of Nursing (DON), further highlighted the deficiencies in the training program. CNAs reported not receiving training on mechanical lifts, and the DON admitted to not having documentation of training sessions. The DON, who had been in the position for three and a half months, was responsible for ensuring staff training but lacked individual records to track the required 12 hours of CNA education. The facility's previous corporate team, which was responsible for providing education, had been removed two weeks prior to the survey, contributing to the lack of training documentation.
Facility Fails to Ensure Communication Training for Staff
Penalty
Summary
The facility failed to ensure that all employees completed communication training, affecting nine out of nine employees reviewed. The facility did not have a plan or system in place to ensure the training would be completed. The facility's assessment and staff training documentation indicated a commitment to providing necessary training and competencies, including effective communication for direct care staff. However, the facility could not provide evidence of an education/compliance calendar when requested, and the general orientation checklist did not include communication training. The employee education files for CNAs O, U, Y, Z, AA, BB, E, Q, and CC showed a lack of documentation for communication training. Some files were missing a general orientation checklist, while others had checklists that did not include communication education. The Director of Nursing, who had been in the position for three and a half months, acknowledged responsibility for ensuring staff education but admitted to not documenting the training provided. He believed Human Resources was responsible for documenting education, leading to a lack of individual records to track CNA education hours.
Deficiency in Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that all employees received training on resident rights, as identified in their facility assessment. Specifically, four Certified Nurse Aides (CNAs) out of nine employees reviewed did not have documentation or evidence of completing the required training on resident rights. The facility's assessment highlighted the importance of staff training and education to provide the necessary support and care for residents, yet the records for CNAs O, Y, AA, and BB showed no evidence of such training. Their employee files lacked a general orientation checklist, and they did not sign attendance for skills fairs or in-service training sessions that included resident rights education. The Director of Nursing (DON), who assumed the role three and a half months prior, acknowledged responsibility for ensuring staff education and training but admitted to not documenting the training provided. The DON mentioned that resident rights were included in the education fair list, but not all staff attended. Additionally, there was no system in place to track the 12 hours of CNA education, and the DON believed Human Resources was responsible for documenting education, which led to a lack of individual records for new hires.
Failure to Complete QAPI Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff completed the required Quality Assurance Performance Improvement (QAPI) process training, as identified in their facility assessment. Specifically, four Certified Nurse Assistants (CNAs) who had been employed for at least one year did not have documentation or evidence of completing the QAPI training. The facility's assessment indicated a commitment to providing necessary training and competencies for staff, but the general orientation checklist did not include QAPI process training. Additionally, the in-service record book and skills fair attendance lists did not show signatures of attendance for the QAPI training for these CNAs. During an interview, the Director of Nursing (DON), who had been in the position for three and a half months, acknowledged the responsibility for ensuring staff education and training but admitted to not documenting the training sessions. The DON mentioned that QAPI was included in the education fair list in July, but not all staff attended. Furthermore, there was no system in place to track the 12 hours of CNA education, and the DON assumed that Human Resources documented the education, which was not the case.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure that all employees completed mandatory education on infection control, as identified in their facility assessment. Specifically, four Certified Nurse Assistants (CNAs) out of nine employees reviewed, who had been working at the facility for at least one year, did not have documentation or evidence of completing the required infection control training. The facility's assessment outlined the importance of providing staff training and competencies necessary for resident care, including infection control topics such as hand hygiene, isolation, and the use of personal protective equipment (PPE). However, the employee education files for CNAs O, Y, AA, and BB lacked a general orientation checklist and did not show any record of infection control training. The Director of Nursing (DON), who had been in the position for three and a half months, acknowledged responsibility for ensuring staff education and training. Despite the facility having an education calendar and conducting skills fairs, some staff did not attend, and there were no individual records to track the required 12 hours of CNA education. The DON believed that Human Resources documented the education, but there was no education check-off for new hires. This lack of documentation and follow-up resulted in a deficiency in the facility's infection prevention and control program.
Failure to Ensure Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that all staff completed compliance and ethics training, as identified in their facility assessment. Specifically, the facility did not have documentation or evidence that the required training was completed for seven Certified Nurse Aides (CNAs) out of nine employees who had been working at the facility for at least one year. The facility's assessment indicated a commitment to providing necessary training and competencies for staff, but there was no evidence of a general orientation checklist or signed attendance for any education or training sessions for these CNAs. During an interview, the Director of Nursing (DON), who had been in the position for three and a half months, acknowledged responsibility for ensuring staff education and training. However, the DON admitted to lacking evidence that all staff attended new hire training or the skills fair. The DON also noted the absence of individual records to track the required 12 hours of CNA education and was under the impression that Human Resources documented the education, which was not the case.
Deficiency in CNA Training Program
Penalty
Summary
The facility failed to ensure an effective training program for Certified Nurse Assistants (CNAs), specifically in the areas of dementia care and abuse prevention. The facility's assessment identified specific training needs, but there was no documentation or evidence that the required training was completed for four out of nine employees reviewed. These employees, who had been working at the facility for at least one year, did not receive the minimum of 12 hours of training annually as required. The facility census was 54, indicating a significant oversight in training compliance. The review of employee education files for CNAs O, Y, AA, and BB revealed that their files did not include a general orientation checklist or documentation of attendance at the facility's general orientation. Additionally, these CNAs did not sign the skills fair attendance list, and their education records did not show the required minimum of 12 hours of training or competencies identified in the facility assessment. This lack of documentation and training was further corroborated by interviews with CNAs M and P, who stated that they did not receive training on mechanical lifts and learned from each other instead. The Director of Nursing (DON), who was responsible for all nursing staff training, acknowledged that dementia training was provided at the skills fair, but not all staff attended. The DON also admitted that mechanical lift training, which was part of the required 12 hours of training for CNAs, was not provided. The DON, who had been in the position for three and a half months, did not have individual records to track the 12 hours of CNA education and believed that Human Resources documented the education, which led to a lack of proper documentation and oversight in training compliance.
Deficiency in Staff Training Compliance
Penalty
Summary
The facility failed to implement an effective training program for both new and existing staff, as identified in their facility assessment. Specifically, the facility did not have documentation or evidence that required behavioral health training was completed for four CNAs out of nine employee education files reviewed. The facility's assessment outlined the necessity for behavioral health training, including topics such as substance use disorder and de-escalation techniques, but the general orientation checklist did not include this training. The employee files for CNAs O, Y, AA, and BB lacked a general orientation checklist and did not show any record of attending behavioral health training or other educational sessions. The Director of Nursing (DON), who assumed the role three and a half months prior, was responsible for ensuring staff education and training. However, the DON was unable to provide documentation of completed training or individual records tracking the required 12 hours of CNA education. Despite multiple requests from the Department of Health and Senior Services (DHSS), no training records were received. The DON believed that Human Resources documented the education, but no evidence was available to confirm this. This lack of documentation and oversight led to the deficiency in staff training compliance.
Facility Fails to Provide Weekend Access to Resident Funds
Penalty
Summary
The facility failed to ensure residents had reasonable access to their personal funds, particularly on weekends. During a resident group interview, several residents reported that they could only access their funds from Monday to Friday, as there was no staff available on weekends to facilitate withdrawals. This issue affected 37 residents whose funds were managed by the facility, and it was confirmed that the facility did not have set banking hours on Saturdays. The facility's policy and admission agreement did not specify banking hours, contributing to the residents' inability to access their funds on weekends. Interviews with the Regional Business Office Manager and the administrator revealed that the administrator was responsible for handling resident funds, which were kept in a cash envelope in the administrator's office. The administrator was unaware of the requirement to provide access to resident funds on weekends. This lack of awareness and the absence of weekend banking hours led to the deficiency, as residents were unable to manage their financial affairs as stipulated in the facility's policy and admission agreement.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by multiple observations of disrepair and lack of maintenance. Observations revealed missing paint and scuff marks on handrails, gouges and scuff marks on resident room doors, and chipped and cracked floor tiles with dirt buildup. Specific instances included a resident room door with gouges and dark lines, walls with gouges and scuff marks, and exposed unpainted drywall. Residents reported having requested repairs, such as painting, for several years without resolution. Interviews with the Maintenance Director and Administrator highlighted a breakdown in the maintenance reporting and repair process. The Maintenance Director indicated that repairs were to be reported through a maintenance request book, but acknowledged that monthly walk-throughs had ceased due to an anticipated facility remodel. The Administrator expected maintenance to address repairs promptly, but the process appeared ineffective, as evidenced by the ongoing issues in resident rooms and common areas. Residents expressed dissatisfaction with the unaddressed maintenance requests, indicating a failure in the facility's system to ensure a safe and homelike environment.
Failure to Complete PASRR Screenings for Residents
Penalty
Summary
The facility failed to ensure that four residents had a Pre-Admission Screening and Resident Review (PASRR) completed prior to admission. The PASRR process is crucial for identifying individuals with mental disorders or intellectual disabilities to ensure they receive appropriate care. The facility's policy mandates coordination with the PASRR program under Medicaid, requiring a Level I screening before admission and a Level II evaluation if necessary. However, the facility did not adhere to this policy for the residents in question. Resident #15, diagnosed with schizophrenia, had no documentation of a Level I or Level II PASRR in their medical record, despite a previous Level II screening completed in 2016. Resident #14, with multiple mental health diagnoses, had a Level I PASRR completed in 2011 without review or approval from the Central Office Medical Registry Unit (COMRU), and a Level II screening from 2009 was unavailable. Resident #3, also diagnosed with schizoaffective disorder, had a Level I PASRR from 2008 without COMRU approval, and Resident #13, with several mental health diagnoses, had a Level I PASRR from 2019 without COMRU review. Interviews with facility staff revealed confusion and lack of clarity regarding the PASRR process responsibilities. The MDS Coordinator and Social Services Director (SSD) were unsure of their roles, and there was a lack of communication and coordination between them. The SSD, who was previously responsible for the PASRR process, indicated that the business office or corporate office might now handle it, but this was not confirmed. The Director of Nursing and Corporate Nurse both stated that the SSD was responsible for ensuring the PASRR process was completed, but the Administrator expected the SSD to coordinate the Level I and Level II screenings. This lack of clear responsibility and oversight led to the deficiency in completing the necessary PASRR screenings for the residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature, as evidenced by multiple resident complaints and observations. Residents reported that their meals were often served cold, with specific instances noted on 08/20/24 and 08/23/24. During these times, residents expressed dissatisfaction with the temperature of their food, describing it as cold or ice cold. Observations confirmed that food temperatures were below the expected safe and appetizing levels, with a test tray showing ground beef tacos at 107.5 degrees Fahrenheit and Spanish rice at 111.2 degrees Fahrenheit, both below the standard serving temperature. The facility's dietary staff did not monitor or record food temperatures during or at the end of meal service, and trays were sometimes delivered without insulated covers, contributing to the issue. The Dietary Manager and Registered Dietician acknowledged the expectation for hot foods to be served hot, but the practice of not checking temperatures mid-meal or at the end of service led to the deficiency. Staff interviews revealed that complaints about cold food were common, and the Director of Nursing was aware of these issues, indicating a systemic problem with maintaining appropriate food temperatures.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpsters used for garbage disposal were kept covered when not in use. During an observation, it was noted that five dumpsters were located outside by the service hall entrance, with the lids on two of them left open. One of these open dumpsters was two-thirds full of garbage, while the other was approximately half full. Additionally, there were multiple pieces of plastic and paper garbage scattered on the ground in front of the dumpsters. Interviews conducted with facility staff revealed that the responsibility for keeping the dumpster lids closed fell to the staff. The Dietary Manager confirmed that he expected the lids to be closed when not in use, and Maintenance Staff K also stated that the dumpster lids should be closed. Despite these expectations, the observation indicated a failure to adhere to this protocol.
Mechanical Lifts Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain its mechanical lifts in good repair and safe operating condition, as evidenced by observations and interviews. The facility had three mechanical lifts, but one was out of service due to a dead battery, and the other two had issues with sticking wheels and legs. Staff were observed using these lifts despite the malfunctions, which included popping and creaking sounds during operation, and the need to kick or jerk the lifts to move them. These issues were not reported to maintenance or the Director of Nursing (DON), contrary to the facility's policy. Observations showed that the lifts had marred legs with black buildup, dirt buildup, and rust on the wheels and wheel-locks. The Invacare RPL450-2 lift made popping and creaking sounds when operated without a resident, and the Invacare RPL600-2 lift had chipping paint on the lift arm and sling attachment point. Despite these conditions, staff continued to use the lifts, and the issues were not communicated to the maintenance department for repair. Interviews with Certified Nurse Assistants (CNAs) revealed that they experienced difficulties using the lifts due to the sticking wheels and legs, but they did not report these issues because the lifts were still usable, albeit with difficulty. The DON and Maintenance Director were unaware of the problems with the lifts, as staff had not tagged the equipment for repair or communicated the need for maintenance. The Administrator expected the lifts to be in proper working order and for any malfunctions to be reported and addressed promptly.
Failure to Report Injury and Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who had unexplained fractures in their legs and failed to report an allegation of staff-to-resident verbal abuse for another resident. The facility's policy required immediate reporting of unexplained injuries to the resident's nurse and completion of an incident report form. However, the facility did not adhere to these procedures. In the case of the resident with unexplained fractures, the staff did not report the injury to the state survey agency within the required two-hour timeframe. The resident, who was cognitively intact and dependent on staff for all activities of daily living, was found to have multiple fractures in their legs, which were not observed or explained by the resident or staff. The resident with unexplained fractures was administered pain medication multiple times, and staff noted swelling and skin tears on the resident's legs. Despite these observations, the staff did not initiate further investigation or reporting. The Director of Nursing (DON) assessed the resident and found swelling but no signs of recent trauma. X-rays revealed multiple fractures, but the DON did not classify the injury as one of unknown origin, as both the staff and resident denied any incidents. The facility's failure to report the injury as required by their policy resulted in a deficiency. In the case of the resident alleging verbal abuse, the resident reported that a CNA used derogatory language and refused assistance to the bathroom. The incident was not reported to the state agency within the required timeframe. The Social Services Designee (SSD) and other staff were aware of the resident's allegations but did not report them as potential verbal abuse. The facility's policies required immediate reporting of such allegations, but the staff failed to follow these procedures, leading to another deficiency.
Failure to Investigate Injuries and Allegations of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who had unexplained fractures in their legs. The resident, who was cognitively intact and dependent on staff for all transfers due to quadriplegia, was found to have skin tears and swelling in the legs. Despite the resident's inability to explain the cause of the injuries and the presence of significant fractures identified through x-rays, the facility did not classify the incident as an injury of unknown origin, nor did they initiate a comprehensive investigation as required by their policy. Additionally, the facility did not investigate an allegation of verbal abuse made by another resident against a staff member. The resident, who was alert and oriented, reported that a CNA had used derogatory language and refused assistance. Despite the resident's clear account of the incident, the facility did not conduct an investigation into the alleged verbal abuse, as the staff involved and other personnel did not report the incident as abuse, and no further inquiry was made. The facility's policies on unexplained injuries and abuse require immediate investigation and reporting of such incidents. However, in both cases, the facility failed to adhere to these policies, resulting in a lack of proper documentation and investigation into the residents' allegations and injuries. This oversight indicates a significant deficiency in the facility's response to potential abuse and injury of unknown origin, as highlighted by the lack of action taken by the staff and administration.
Failure to Notify State Authority for PASRR Level II
Penalty
Summary
The facility failed to notify the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASRR) for two residents with diagnoses of mental disorders or intellectual disabilities. Resident #8, initially admitted in 2016, had a Level I screening that did not indicate the need for a Level II evaluation despite having diagnoses of major depressive disorder and schizoaffective disorder. The resident was re-admitted in 2018 from a psychiatric hospital, but a Change in Status PASRR was not submitted to the Central Office Medical Review Unit (COMRU) as required. Resident #13, originally admitted in 2019 and most recently in 2023, had a Level I screening without review or approval from COMRU, and a Level II screening was not triggered. The resident had primary diagnoses of major depressive disorder, schizophrenia, anxiety, and alcohol-induced persisting dementia. After a psychiatric evaluation and hospital stay in 2023, a Change in Status PASRR was not submitted despite a change in the nursing facility's primary admitting diagnosis. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The MDS Coordinator and Social Service Director (SSD) were unclear about their roles, and there was confusion about who was responsible for ensuring the PASRR process was completed. The SSD believed the business office or corporate office was handling the process, while the Director of Nursing and Corporate Nurse indicated that the SSD was responsible. The Administrator expected the SSD to ensure Level I screenings were done and coordinate any necessary Level II screenings with COMRU.
Failure to Provide Necessary ADL Care and Incontinence Checks
Penalty
Summary
The facility failed to provide necessary care and services for three residents who were unable to perform their own activities of daily living (ADLs). This included maintaining bathing, grooming, personal hygiene, and nail care. Additionally, the facility did not check one resident for incontinence for a prolonged period, resulting in the resident being wet and soiled. These deficiencies were identified through observation, interview, and record review, and were noted as uncorrected from a previous Statement of Deficiencies.
Failure to Administer Medication and Follow Up on Lab Tests Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services to a resident with known liver disease, resulting in the resident becoming lethargic and dehydrated, with critically elevated levels of ammonia, sodium, and chloride, and elevated kidney function tests indicating severe dehydration and kidney failure. The resident was hospitalized due to these conditions. The facility did not administer lactulose, a medication critical for managing the resident's liver condition, as ordered by the physician. The medication was not given on multiple occasions, and there was no documentation of staff notifying the physician about the missed doses. Additionally, the facility did not follow up on a laboratory test ordered for the resident. A Complete Blood Cell Count and Comprehensive Metabolic Panel were ordered, but the specimen was hemolyzed, and no repeat blood draw was completed. This lack of follow-up on critical laboratory tests contributed to the resident's deteriorating condition, as the facility failed to monitor and address the resident's health needs adequately. Interviews with staff revealed that the resident was known to refuse medication at times, and staff had methods to encourage medication intake, such as mixing lactulose with coffee. However, these methods were not consistently applied, leading to missed doses. The facility's staff, including the LPN and ADON, failed to notify the physician of the resident's significant change in condition, which included lethargy, high blood pressure, and unresponsiveness. The physician indicated that earlier notification might have led to a different outcome for the resident.
Insufficient Nursing Staff and Scheduling Deficiency
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of eight residents out of a sample of 28. This deficiency was identified through observation, interviews, and record reviews. Additionally, the facility did not ensure that licensed staff were scheduled according to the facility's assessment to meet the residents' needs. The facility had a census of 65 residents at the time of the survey.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide adequate housekeeping services, resulting in a deficiency related to maintaining a clean, safe, and comfortable homelike environment for residents. Observations, interviews, and record reviews revealed that resident rooms, hallways, and common areas were not clean and were free of odors. Additionally, the floors were not clean and were littered with debris, and trash in resident rooms was not emptied. This deficiency was noted in a facility with a census of 65 residents.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice by not administering medications to two residents within the designated time frame for the morning medication pass. Additionally, staff left a resident's medications on the bedside table without observing the resident take them, which is against standard practice. Furthermore, a controlled medication was not administered to another resident as ordered by the physician. These deficiencies were identified during a review of 28 sampled residents in a facility with a census of 65.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary care and services for three residents who were unable to perform their own activities of daily living (ADLs). This deficiency was identified through observation, interview, and record review. The residents did not receive adequate assistance with bathing, grooming, including shaving, personal hygiene, and nail care. The review was conducted on a sample of 28 residents, and the facility had a census of 65 at the time of the survey.
Non-compliance with Staffing Requirements
Penalty
Summary
The facility failed to ensure compliance with staffing requirements by not having the Director of Nursing (DON) refrain from working as a charge nurse when the facility census exceeded 60 residents. This deficiency was observed on multiple occasions, specifically on 4/1/24, 4/3/24, 4/4/24, 4/8/24, and 4/9/24, when the facility census was 65. The report indicates that this issue has been previously noted and remains uncorrected, as referenced in the Statement of Deficiencies dated 2/23/24.
Failure in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with standards of practice for the assessment, prevention, and promotion of healing of pressure ulcers for one resident. This deficiency was identified through observation, interview, and record review. The resident was among a sample of 28 residents reviewed, within a facility census of 65. The report highlights a specific incident where the facility did not adequately address the needs related to pressure ulcer care for this resident.
Misappropriation of Narcotic Medications by LPN
Penalty
Summary
The facility failed to ensure that three residents were free from misappropriation of property when an LPN misappropriated residents' narcotic medications. The incident involved the LPN signing out narcotic medications for residents but not administering them as documented. This was discovered when a resident reported not receiving their pain medication, despite it being signed out by the LPN. Upon investigation, it was found that the LPN had the medication in their pocket and had not administered it to the resident as required. Further review revealed that the LPN had signed out multiple doses of narcotic medications for other residents without documenting their administration. This included instances where the LPN signed out medications but did not record their administration on the Medication Administration Record (MAR). The discrepancies were noted over several days, indicating a pattern of misappropriation of narcotic medications by the LPN. The facility's policies on abuse, neglect, and controlled substance administration were not followed by the LPN. The policies required that all controlled substances be recorded and administered as documented, with any discrepancies resolved immediately. The LPN's actions of signing out medications and not administering them, as well as carrying medications in their pocket, were clear violations of these policies. The facility identified the issue and took immediate action to investigate and address the misappropriation of medications by the LPN.
Infection Control and Incontinence Care Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed for two residents during blood glucose monitoring. Specifically, staff did not appropriately sanitize the glucometer machine after use. One resident had Hepatitis C, and the glucometer was not disinfected according to the manufacturer's instructions, which required the use of specific disinfectant wipes. Instead, the staff used alcohol pads and did not place a barrier between the glucometer and surfaces in the resident's room. Additionally, the staff member cleaned the glucometer with bare hands and did not have access to the necessary disinfectant wipes during the night shift, leading to improper sanitization practices between residents' uses of the glucometer. The staff member was unaware of the residents' infectious disease status and did not follow the facility's policy for cleaning and disinfecting the glucometer properly. The Director of Nursing (DON) and the administrator confirmed that the staff did not follow the expected procedures for infection control and glucometer disinfection. The facility's policy required the use of specific disinfectant wipes, which were not available on the medication cart, leading to the use of inadequate cleaning methods. The staff's failure to follow proper infection control practices posed a risk of cross-contamination and infection transmission among residents. The facility also failed to provide proper incontinence care for two residents. Staff did not follow the facility's perineal care policy and procedure, which required changing gloves and performing hand hygiene when moving from a dirty process to a clean process. The staff member used the same cloth surface multiple times during perineal care, did not change gloves when soiled, and touched clean items with contaminated gloves. The DON confirmed that staff were expected to change gloves, wash hands, and use a different cloth surface for each wipe during incontinence care. The staff's failure to adhere to these procedures compromised the residents' hygiene and increased the risk of infection. The facility's failure to follow proper infection control and incontinence care practices led to an Immediate Jeopardy (IJ) situation, which was later removed after corrective actions were implemented. However, the deficiency was still present at the time of the survey, and a final revisit was planned to determine if the facility was in substantial compliance with participation requirements.
Failure to Ensure Residents Can Voice Concerns Without Fear of Retaliation and Lack of Dignity in Resident Care
Penalty
Summary
The facility failed to ensure that three residents felt they could voice concerns to staff or the state agency without fear of retaliation. Residents reported that staff would take longer to respond to call lights or refuse to provide assistance after complaints were made. One resident specifically mentioned being told by a staff member that if they contacted the state agency or abuse hotline, they could look for another place to live. These residents felt their grievances were not resolved and that staff ignored their needs as a form of punishment for voicing concerns. Additionally, the facility failed to treat one resident with dignity and respect. This resident, who was cognitively impaired and at high risk for falls, was found on the floor and requested help to get back into bed. A staff member told the resident to stay on the mat and be quiet, refusing to assist them back into bed. This incident was captured on video and corroborated by the resident, who felt helpless and upset by the staff's actions. Interviews with the Director of Nursing and the Administrator revealed that they did not expect staff to ignore residents' call lights or requests for help, nor did they expect residents to fear retaliation for voicing concerns. However, the evidence showed that staff did not respond promptly to residents' needs and, in some cases, treated residents with a lack of dignity and respect, leading to the deficiencies noted in the report.
Inadequate Supervision and Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate care and supervision for three residents, leading to significant incidents. Resident #6 fell out of bed during incontinence care due to improper positioning by a CNA, resulting in injuries that required emergency room care. The resident's low air loss mattress was also set incorrectly for their weight, which may have contributed to the fall. Despite the resident's known risk for falls and the availability of adequate staff, the CNA did not seek additional help when the resident began moving towards the edge of the bed, leading to the fall and subsequent injuries including a laceration and bruising on the face and a splint on the right hand/thumb. Resident #5 was improperly transferred using a Hoyer lift by only one staff member, contrary to the care plan and physician's orders that required two staff members for such transfers. This action was taken despite the resident's diagnosis of Friedreich's ataxia, which necessitates careful handling and assistance. The CNA admitted to transferring the resident alone because the resident was small, but acknowledged that this was against protocol. Resident #15, who resides on a locked dementia unit and is on a pureed diet, was left unsupervised with a peanut butter and jelly sandwich within reach. The resident, who has difficulty swallowing and is at risk of choking, ate the sandwich without staff knowledge. This occurred despite the facility's policy requiring close monitoring of residents during meals to prevent accidents. Both the CNA and RN present in the dining room failed to notice the resident consuming the sandwich, highlighting a lapse in supervision and adherence to dietary restrictions.
Inadequate Staffing and Oversight
Penalty
Summary
The facility failed to ensure adequate staffing to provide resident care and protective oversight. The facility's assessment indicated that the number of residents the facility was licensed to care for was 180, with an average daily census range of 70-80. However, from 11:00 P.M. on 11/5/23 to 3:52 A.M. on 11/6/23, there were only three staff members caring for 71 residents. Interviews with various staff members revealed that it was difficult to adequately provide care, including answering call lights timely, with the amount of staff they had. Additionally, there were instances of staff sleeping while on duty, further compromising resident care. The facility's policy, dated 9/1/21, stated that sufficient staff with appropriate competencies and skill sets should be provided to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Despite this policy, the facility's staffing sheet and time card punches showed significant staffing shortages during the night shift on 11/5/23. The staffing coordinator and other staff members confirmed that there were not enough staff to cover call-ins, and administration was aware but had not taken corrective actions. Interviews with various staff members, including CNAs, LPNs, and RNs, highlighted the challenges faced due to inadequate staffing. Staff reported that it was not possible to answer call lights quickly, and some staff members were found sleeping while on duty. The Director of Nursing and the facility's corporate nurse acknowledged the staffing issues and the failure to notify appropriate personnel of the staffing shortage. The administrator admitted to being unaware of the staffing deficiencies and stated that staff sleeping on duty would be grounds for termination according to the employee handbook.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
