Aspire Senior Living Advance
Inspection history, citations, penalties and survey trends for this long-term care facility in Advance, Missouri.
- Location
- 315 South Tilley Street, Advance, Missouri 63730
- CMS Provider Number
- 265550
- Inspections on file
- 15
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Aspire Senior Living Advance during CMS and state inspections, most recent first.
The facility failed to have an appropriate diagnosis for one resident's antipsychotic order and failed to limit another resident's PRN antipsychotic order to 14 days. One resident received quetiapine for depression despite diagnoses including Parkinson's disease with dyskinesia, and another resident had haloperidol PRN for hallucinations with no stop date. The DON, Administrator, and MD stated psychotropic meds should have an appropriate diagnosis and PRN antipsychotics should have a 14-day stop date.
A resident with type 2 DM had repeated missed Lantus doses despite an order for bedtime insulin, and staff interviews showed confusion about why the insulin was held and no physician notification for the blood sugars. In a separate event, the DON performed wound care for a resident with venous insufficiency and chronic leg ulcers but omitted ordered skin prep and mupirocin during treatment of the heel and posterior leg wounds.
Failure to individualize care plans for residents with dementia: The facility did not ensure that two residents with dementia had care plans that addressed their dementia-related needs, including specific problems, interventions, goals, or activity needs. One resident had diagnoses of unspecified dementia and Alzheimer's disease with moderate cognitive impairment, and another had dementia with hallucinations, restlessness, agitation, and fluctuating cognitive impairment. Staff interviews confirmed the care plans should have reflected dementia and personalized interventions, and the Activity Director stated the facility did not have specialized activities for dementia residents.
Improper Labeling and Use of Expired Medications: An opened methadone concentrate bottle for a resident was found undated on the med cart, and the controlled med record showed it was administered multiple times after the 90-day expiration period. An opened tuberculin PPD multidose vial was also found undated in the med storage refrigerator, despite staff stating multi-dose vials should be dated when opened and discarded when expired.
Unsanitary food storage and equipment cleaning: Surveyors found food particles, grime, and buildup in the microwave, air fryer, and reach-in cooler, along with unlabeled or improperly dated food items, an uncovered cabbage, opened condiments without dates, and a dented can. Dietary staff said they had not cleaned the microwave or air fryer and were unsure when cleaning was required, while the Dietary Mgr and Admin acknowledged labeling, dating, covering, and cleaning expectations.
Failure to Disinfect Glucometers per Policy: A CMT performed blood glucose testing for four residents using two glucometers and wiped each device with a disinfecting wipe without allowing the required wet contact time before air drying. The facility policy and manufacturer instructions required the glucometer to be thoroughly disinfected after each use, and the CMT stated he/she was not aware of the wet contact time. The DON and Administrator stated staff were expected to disinfect glucometers per policy and wipe instructions.
The facility failed to provide timely written notification to residents and/or their representatives regarding hospital transfers, as required by policy. Three residents experienced multiple transfers without documented written notification. Interviews revealed a misunderstanding of the policy, with paperwork being left in the resident's room upon return rather than provided at the time of transfer.
The facility did not inform three residents or their representatives of the bed hold policy at the time of hospital transfer, as required by their policy. The Social Services Director left the paperwork in the resident's room instead of providing it at the time of transfer, contrary to the Administrator's expectations.
The facility failed to accurately code the MDS for three residents, leading to discrepancies in their medical records. A resident's admission MDS did not document several diagnoses and medications, another resident's quarterly MDS inaccurately indicated anticoagulant use, and a third resident's annual MDS omitted diagnoses and a fall. Interviews revealed an expectation for accurate MDS coding, but no policy was provided to ensure this.
The facility failed to assess and document the use of bed rails for five residents, including those with cognitive intactness and varying mobility needs. Despite observations of bed rail use, there was no documentation of assessments or informed consent explaining the risks and benefits. The facility also lacked a policy on bed rails, and interviews with the DON and Administrator confirmed the expectation for such documentation, which was not met.
A facility failed to provide a personalized care plan for a resident with dementia, omitting specific problems, interventions, or goals for dementia care. Observations showed the resident was mobile in a wheelchair, and interviews with staff confirmed the oversight in care planning.
The facility failed to ensure appropriate diagnoses for psychotropic medication use in two residents within the sample and one outside the sample. A resident was prescribed quetiapine without a proper diagnosis, while another had an incorrect diagnosis entered into the electronic medical record. A third resident was prescribed haloperidol with a pharmacy recommendation for renewal every 14 days. Interviews confirmed the inappropriateness of the diagnoses, and the facility lacked a policy for appropriate psychotropic medication diagnosis.
A facility failed to maintain a medication error rate below five percent, resulting in an 11.11% error rate due to improper insulin pen priming. A CMT did not prime insulin pens before administering insulin to three residents with type 2 diabetes, contrary to facility policy. Interviews revealed the CMT was unaware of the priming requirement, while other staff confirmed the expectation to prime insulin pens.
The facility failed to label and store medications properly, affecting all residents. Observations revealed opened vials of Tubersol without dates and several insulin pens not dated when opened. Staff interviews confirmed that medications should be dated and checked regularly, aligning with the facility's policy.
The facility failed to maintain proper infection control practices and TB screening. Staff did not adhere to glove use and enhanced barrier precautions during care activities, such as wound and catheter care. Observations showed inadequate hand hygiene and glove changes during incontinence care. Additionally, the facility did not ensure proper TB screening for residents upon admission, as required by policy.
Facility staff did not post the required DHSS hotline and SSA contact information in an accessible manner for residents and their representatives. Observations showed the absence of this information, and interviews with residents and staff revealed a lack of awareness or incorrect assumptions about its posting. The Administrator confirmed that the hotline number should be posted.
The facility failed to provide the required twelve hours of annual in-service education for CNAs, affecting one CNA who only received eight hours. The DON and Administrator confirmed the expectation of twelve hours annually, but no policy was provided.
Inappropriate diagnosis for one antipsychotic order and PRN antipsychotic without required stop date
Penalty
Summary
The facility failed to have an appropriate diagnosis for an antipsychotic medication for one resident and failed to limit a PRN antipsychotic medication to 14 days for another resident. The report states that the facility policy required psychotropic medications to be used only when a practitioner determined they were appropriate for a resident's specific, diagnosed, and documented condition, and that PRN antipsychotic orders were limited to 14 days with no exceptions. For Resident #16, the medical record showed diagnoses of drug induced dyskinesia, polyneuropathy, Parkinson's disease with dyskinesia, and depression. The resident had an order for quetiapine 25 mg by mouth one time a day for depression. A monthly medication review requested that the quetiapine dosage be decreased, but the diagnosis of depression was not addressed. The report states the facility failed to have an appropriate diagnosis for the quetiapine. For Resident #27, the medical record showed diagnoses including dementia with mood disturbance, major depressive disorder, anxiety, neurocognitive disorder with Lewy bodies, epilepsy, pain, agitation and restlessness, fibromyalgia, hallucinations, and Parkinson's disease. The resident had an order for haloperidol 0.5 mg by mouth every 6 hours PRN for hallucinations with no stop date. A pharmacy note requested the prescriber address the order, and the physician responded to continue the PRN haloperidol for psychosis, but no stop date was added. During interviews, the DON, Administrator, and Medical Director stated they expected psychotropic medications to have an appropriate diagnosis and PRN antipsychotics to have a 14-day stop date.
Failure to Follow Physician Orders for Insulin and Wound Care
Penalty
Summary
The facility failed to follow physician orders when administering Lantus for a resident with type 2 diabetes mellitus. The resident had an order for Lantus 8 units subcutaneously at bedtime, but the Medication Administration Record showed multiple missed doses across October 2025 through February 2026. The missed administrations were documented on numerous dates, including one missed dose in October, six in November, 10 in December, 14 in January, and nine in February, with blood sugar values recorded on those dates. During interview, RN A said insulin should be given as ordered and stated that if the resident's blood sugar was under 70, a snack would be given and then the Lantus would be administered. RN A did not know why the resident's Lantus was held other than maybe nursing judgment. The Medical Director stated physician orders should be followed as ordered and that if there was a concern about an order, the physician should be notified for clarification. LPN D stated he/she did not hold the resident's Lantus and believed the medication was charted incorrectly, saying the doses shown as not administered had actually been given. LPN D also stated he/she did not notify the physician regarding the resident's blood sugars. The facility also failed to follow wound care orders for another resident with venous insufficiency, non-pressure chronic ulcers of both lower legs, and peripheral vascular disease. The resident had orders for wound cleansing with Vashe, skin prep to the peri wound, mupirocin ointment, calcium alginate silver dressing, ABD pad, and gauze wrap for multiple wounds. During observation, the DON provided treatment to the left heel wound but did not apply the skin prep to the peri wound or the mupirocin ointment as ordered, and did not apply skin prep to the left posterior leg wound as ordered. The DON stated she forgot to apply the skin prep and mupirocin ointment to the resident's left leg and heel as ordered.
Failure to Individualize Care Plans for Residents With Dementia
Penalty
Summary
The facility failed to ensure that residents diagnosed with dementia had personalized care plans that addressed their medical, nursing, psychosocial, and activity needs. For Resident #5, the medical record showed an admission date of 03/04/25 and diagnoses of unspecified dementia and Alzheimer's disease. The quarterly MDS dated 01/05/26 identified dementia and moderate cognitive impairment, but the care plan revised 12/30/25 did not address dementia, did not include specific problems, interventions, or goals for dementia care, and did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. For Resident #27, the medical record showed diagnoses of dementia, hallucinations, restlessness, and agitation. The quarterly MDS showed dementia, cognitive impairment, and fluctuating inattention, disorganized thinking, and altered level of consciousness. The care plan reviewed 02/26/25 failed to address dementia and did not include specific problems, interventions, or goals for dementia care or for activities for a resident diagnosed with dementia. During interviews, the MDS Coordinator said the care plan should address dementia with personalized interventions, the Administrator said she would expect the care plan to reflect a diagnosis of dementia, and the Activity Director said the facility did not have any specialized activities for dementia residents.
Improper Labeling and Use of Expired Medications
Penalty
Summary
Medications and biologicals were not labeled in accordance with accepted practices for one resident and one medication storage area. Resident #27 had an order for methadone concentrate 10 mg/ml, 0.5 ml by mouth every 1 hour as needed for pain, with a start date of 12/03/24 and no adverse reactions identified related to its use. On observation of the 200 Hall medication cart, an opened bottle of methadone concentrate 10 mg/ml with 17 ml remaining was found not dated for the resident. Review of the controlled medication count sheet showed the bottle was first used on 04/16/25 and doses were administered repeatedly after the 90-day expiration date, including 13 administrations beyond the expiration date of 07/15/25. In the medication storage room refrigerator, an opened tuberculin purified protein derivative 1 ml multidose vial was observed not dated. Facility staff stated the tuberculin solution should be dated when opened and discarded when expired per the box directions and manufacturer guidance, and the Administrator stated multi-dose vials should be dated when opened and discarded when expired. The Administrator and DON also stated expired medications should not be administered to residents.
Unsanitary food storage and equipment cleaning
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions. Review of facility policies showed requirements for cleaning food contact surfaces and refrigeration units, inspecting and properly storing food on receipt, labeling and dating refrigerated food and leftovers, and discarding previously cooked foods after three days in refrigeration at 41 degrees Fahrenheit or lower. The February 2026 Dietary Cleaning List showed no documentation that the bottom of the fridge was cleaned daily from 02/19/26 through 02/28/26, with 10 of 28 missed opportunities, no documentation for weekly duties for the month of February with four of four missed opportunities, and no listing for the microwave and air fryer. Observations of the kitchen on 02/24/26 and 02/27/26 showed food particles and brown grime inside the microwave, a black buildup and food crumbs in the air fryer basket, and grime and food particles on the air fryer handle. Unlabeled or improperly labeled items were observed, including a container of shell noodles without a label or date, a container of brown sugar without a label or date, baking powder without a date, white sugar incorrectly labeled as brown sugar and dated 01/25/26, a dented can of black-eyed peas, and an opened bag of shelled pecans without a date opened. In the reach-in cooler, surveyors observed food particles and a dried brown substance on the floor, an uncovered head of cabbage that was shriveled and brown in spots, opened bottles of ranch dressing and heavy-duty mayonnaise without dates opened, and a bottle labeled sweet pickle relish containing a white substance with green particles. Dietary staff stated they had not cleaned the air fryer or microwave and were not sure when they needed to be cleaned, while the Dietary Manager and Administrator acknowledged that items removed from original packaging should be labeled and dated, dented cans should not be used, food should be covered, and equipment should be cleaned per the schedule.
Failure to Disinfect Glucometers per Policy
Penalty
Summary
The facility failed to follow infection prevention measures when staff did not properly disinfect the glucometer used for blood glucose testing for four sampled residents. The facility policy required blood glucometers to be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use. The manufacturer's instructions for the Quintet AC Blood Glucose Meter and Super Sani-Cloth required the meter to be thoroughly wiped, allowed to remain wet for two minutes, and then air dried after each use. During observation, a CMT performed blood glucose testing for Residents #18, #28, #4, and #1 using two glucometers from the medication room. After each resident's testing, the CMT wiped the glucometer with a Super Sani-Cloth but did not allow the surface to remain wet for two minutes. The CMT stated he/she had been taught to wipe the glucometer down and use another glucometer while the first one air dried and was not aware of a wet contact time. The DON stated she expected staff to wrap the glucometer with a Super Sani-Cloth for the wet contact time on the wipe label, and the Administrator stated glucometers should be disinfected per facility policy.
Failure to Provide Timely Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and/or their representatives regarding transfers or discharges to a hospital, as required by their policy. This deficiency was identified for three residents out of a sample of 12, with a facility census of 34. The facility's policy, dated March 2015, mandates that the reason for transfer be explained to the resident or their representative, and a signed transfer or discharge notice be provided. In cases of emergency transfers, the notice may be completed later but should be done as soon as possible. However, for Residents #1, #28, and #32, there was no documentation indicating that they or their representatives were informed in writing of their transfers to the hospital at the time of the transfers. Resident #1 experienced multiple transfers to the hospital between February and July 2024, yet there was no evidence of written notification for any of these instances. Similarly, Resident #28 was transferred to the hospital in January 2024 without documented written notification. Resident #32 was transferred multiple times between April and June 2024, also without written notification. Interviews with the Social Services Director and the Administrator revealed a misunderstanding of the policy, with the Social Services Director indicating that the paperwork was left in the resident's room upon their return, rather than being provided at the time of transfer.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their legal representatives of the bed hold policy at the time of transfer to the hospital for three residents out of a sample of twelve. The facility's policy requires that residents be notified of the bed hold policy at admission and again prior to a hospital transfer or therapeutic leave. In cases of emergency transfer, the policy mandates that written notification be provided within 24 hours of the transfer. However, for Residents #1, #28, and #32, there was no documentation indicating that they or their representatives were informed in writing of the bed hold policy at the time of their transfers to the hospital. Interviews with facility staff revealed a misunderstanding or misapplication of the policy. The Social Services Director indicated that the bed hold policy paperwork was filled out but not given to the resident until it was confirmed that the resident would be admitted to the hospital, leaving the paperwork in the resident's room for when they returned. The Administrator, however, stated that the expectation was for the bed hold notice to be given to the resident and/or their representative at the time of the transfer. This discrepancy in practice contributed to the failure to comply with the facility's policy and regulatory requirements.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to discrepancies in their medical records. Resident #6's admission MDS did not document diagnoses of hypertension, hypothyroidism, and seizure disorder, nor did it include hypoglycemic medication, despite these being present in the medical record. Resident #11's quarterly MDS inaccurately indicated the resident was receiving an anticoagulant, although the order for Eliquis had been discontinued, and no current order for an anticoagulant was present. Resident #32's annual MDS failed to document diagnoses of GERD and cerebral infarction, as well as a fall that occurred on 09/12/24. Interviews with the facility's Administrator and MDS Coordinator revealed an expectation that the MDS should accurately reflect the residents' current conditions. However, the facility did not provide a policy regarding MDS accuracy, contributing to the inaccuracies found in the assessments of the sampled residents. The facility census at the time was 34, and the deficiencies were identified in 3 out of 12 sampled residents.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to appropriately assess and document the use of bed rails for five residents, including four sampled residents and one outside the sample. The residents involved were cognitively intact and had varying levels of mobility and fall risks. However, the facility did not conduct bed rail assessments or obtain informed consent explaining the risks and benefits of bed rail use for these residents. Observations showed that these residents were using bed rails, but their medical records lacked necessary documentation, and the facility did not provide a policy regarding bed rails. Resident #1, who was cognitively intact and required supervision with bed mobility, was observed using bed rails without documented assessments or informed consent. Similarly, Resident #2, who was independent with bed mobility but had a history of dementia and repeated falls, used bed rails without proper documentation. Resident #3, with a left below-knee amputation, used a halo bar for mobility assistance, yet there was no documentation of bed rail assessments or informed consent. Resident #7 had an order for bed rails but lacked documentation of assessments and consent, and Resident #28, who was dependent on bed mobility due to a stroke and other conditions, also used bed rails without the necessary documentation. Interviews with the DON and Administrator confirmed the expectation for assessments and informed consents, which were not met in these cases.
Failure to Address Dementia in Resident Care Plan
Penalty
Summary
The facility failed to provide a personalized plan of care for a resident diagnosed with dementia, which is necessary to ensure appropriate services and promote the resident's highest level of functioning and psychosocial needs. The resident's medical record indicated a diagnosis of unspecified dementia and a cognitive communication deficit. However, the care plan did not address dementia, nor did it include specific problems, interventions, or goals for dementia care or activities tailored to the resident's condition. Observations showed the resident was able to self-propel in a wheelchair around the dining room and nurse's station, and was also seen sitting in the dining room. Interviews with the Director of Nursing, the Administrator, and the MDS coordinator confirmed that dementia should have been addressed in the care plan, indicating a lapse in the facility's care planning process for residents with dementia.
Inappropriate Diagnosis for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of psychotropic medications for two residents within the sample and one resident outside the sample. Resident #9 was prescribed quetiapine for unspecified dementia without behavioral disturbance and anxiety disorder, but there was no documentation of an appropriate diagnosis for the medication. Similarly, Resident #11 was prescribed quetiapine for unspecified dementia without behaviors, which was noted by the pharmacy as an inappropriate diagnosis. Despite this, the physician did not address the need for a correct diagnosis. Resident #15 was prescribed haloperidol for hallucinations and paranoia, with a pharmacy recommendation for renewal every 14 days, which was documented by the physician. Interviews with the Director of Nursing and the Administrator confirmed that unspecified dementia without behaviors is not an appropriate diagnosis for antipsychotic medication. Physician K acknowledged that the diagnosis for Resident #11 was incorrect in the electronic medical record, suggesting a clerical error. The facility did not provide a policy regarding the appropriate diagnosis for psychotropic medication, contributing to the deficiency in ensuring proper medication management for residents.
Medication Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 11.11% for three residents out of 12 sampled. The errors were related to the administration of insulin without priming the insulin pens as required by the facility's policy. Specifically, the Certified Medication Technician (CMT) D did not prime the insulin pens with two units before administering the insulin to Residents #1, #8, and #32, all of whom had a diagnosis of type 2 diabetes mellitus and were receiving insulin as part of their treatment. During observations, CMT D administered insulin to the residents without performing the necessary priming step, which was confirmed through interviews. CMT D admitted to never priming insulin pens before, while the Licensed Practical Nurse (LPN) E and the Director of Nursing (DON) both stated that they expected insulin pens to be primed before administration. The Administrator also confirmed the expectation for insulin pens to be primed prior to administration, indicating a lapse in adherence to the facility's medication administration policy.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and store medications, which had the potential to affect all residents. During an observation of the medication room refrigerator, two opened vials of Tubersol were found without an opened date, contrary to the manufacturer's recommendation that the medication be discarded 30 days after opening. Additionally, two unopened vials of nafcillin with an expiration date of 12/2023 were found in the medication room STAT safe. Further observations of the medication cart revealed several insulin pens, including Lantus, insulin lispro, insulin aspart, and basaglar, that were opened but not dated. Interviews with facility staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Administrator, confirmed that multi-dose vials and insulin pens should be dated when opened, and medication expiration dates should be checked regularly. The CMT and LPN indicated that they checked medication dates as they were used and weekly, while the DON and Administrator expected expiration dates to be checked at least monthly. The facility's policy on the storage of medications, although undated, stated that no discontinued or outdated medications should be used and that multi-dose vials should be discarded within 28 days of opening unless otherwise specified by the manufacturer.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during care activities for several residents. Observations revealed that staff did not adhere to the facility's policies on glove use and enhanced barrier precautions. For instance, during wound care for a resident, a CNA did not wear a gown as required by the enhanced barrier precautions. Similarly, during catheter care for another resident, a CNA also failed to wear a gown, despite signage indicating the need for such precautions. In addition to the issues with barrier precautions, the facility did not ensure proper hand hygiene and glove changes during incontinence care. Observations showed that CNAs did not change gloves or perform hand hygiene between different stages of care, such as moving from dirty to clean tasks. This was evident in the care provided to multiple residents, where CNAs touched clean items with potentially contaminated gloves or bare hands. The facility also failed to conduct proper tuberculosis screening for residents upon admission. The medical records of several residents lacked documentation of the two-step TB testing, which is required by the facility's policy. Interviews with staff, including the Administrator and DON, confirmed that some residents did not receive the necessary TB testing, and staff were expected to follow guidelines for infection control, which were not adhered to in these instances.
Failure to Post Required Hotline Information
Penalty
Summary
Facility staff failed to post the required contact information for the Department of Health and Senior Services (DHSS) hotline and the State Survey Agency (SSA) in a manner accessible to residents and their representatives. Observations conducted from November 19 to November 21, 2024, revealed that the facility did not display the name, address, and toll-free telephone number for the DHSS Abuse and Neglect Hotline or the SSA information. During a group interview, six residents expressed that they were unaware of how to find the state hotline number and had not seen it posted. Interviews with facility staff, including a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), and the Social Services Designee (SSD), indicated a lack of awareness or incorrect assumptions about the posting of the hotline number. The Administrator acknowledged that the DHSS Abuse and Neglect Hotline number should be posted.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) received the required twelve hours of in-service education annually, specifically affecting one out of two sampled CNAs, referred to as CNA B. CNA B's in-service record indicated a hire date of September 1, 2021, and showed only eight hours of annual in-service training for the period from November 2023 through November 2024, which is less than the required twelve hours. During interviews, both the Director of Nursing (DON) and the Administrator confirmed that CNAs were expected to attend at least twelve hours of in-service training annually. However, the facility did not provide a policy regarding in-service training, contributing to the deficiency.
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.
