Athene Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Town And Country, Missouri.
- Location
- 13995 Clayton Road, Town And Country, Missouri 63017
- CMS Provider Number
- 265001
- Inspections on file
- 41
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Athene Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident’s personal debit card was used without authorization to make multiple ATM withdrawals at a casino, totaling nearly $2,000. Bank records, transaction reports, and casino surveillance linked a housekeeping supervisor and a CNA to the withdrawals and attempted withdrawals. Police interviews documented that the CNA admitted being at the casino with the supervisor, retrieving a bank card from a car, and using a PIN provided by the supervisor, while the supervisor denied making or witnessing ATM withdrawals despite video and photo evidence placing both staff at the casino during the fraudulent transactions.
The facility failed to obtain and administer ordered medications for two residents, resulting in repeated missed doses documented on the MARs. One resident with schizophrenia and other psychiatric diagnoses had an order for daily cariprazine, but staff repeatedly documented the drug as on order or unavailable over an extended period, with no evidence of administration and no documented physician notification, while behavioral issues and a resident‑to‑resident altercation were recorded. A pharmacy representative later reported that no prescription for this medication was sent by the facility during the relevant time. Another resident with alcoholic cirrhosis and hepatic encephalopathy had an order for rifaximin twice daily for 14 days, but it was not documented as given; the pharmacy did not dispense it due to a high out‑of‑pocket cost, and although an NP was told it was not covered and stated it still needed to be dispensed, the NP was not informed that the medication was never administered, and the administrator was unaware of the omission.
Surveyors found that the facility did not post the Missouri DHSS Elder Abuse and Neglect Hotline number or State Long-Term Care Ombudsman contact information in visible locations throughout multiple units, including elevators, Terrace 2 and 3, 3 Short, 3 Long, and the Loop. Instead, only corporate compliance and administrator contact information were prominently displayed, while the Ombudsman number appeared only on a very small label on a Resident Rights poster outside the Social Worker’s office, and no DHSS hotline number was observed there. During a resident council meeting, eight residents reported they were not aware of the Ombudsman program and confirmed that information about it was not posted. The Administrator stated he believed hotline signs should be present in a few specific areas and expected the Ombudsman print to be large enough for residents to see, but survey observations did not confirm adequate, visible posting facility-wide.
Surveyors found that the facility failed to maintain clean, homelike conditions in multiple resident rooms and common areas. Two residents with conditions including osteomyelitis, cellulitis, and lymphedema had visibly soiled bed linens, accumulated trash, used towels and washcloths left on floors, and personal clothing stored in trash bags, with one resident’s IV pole covered in thick, dried residue. Staff interviews revealed inconsistent practices and understanding of responsibilities for changing linens and removing soiled items. On a resident unit, shower rooms contained wet and stained linens left over multiple days, a fire extinguisher cabinet and nearby artwork had large unidentified stains, and an elevator and adjacent walls had sticky floors and splatter. The dining room had cracked and broken windows, one partially covered with cardboard, and a loose handrail was observed near a room. Another room’s floor remained dirty with trash and dust-like splatter over several days, and the main loop hallway had strong odors of urine, sweat, and bowel movement, sticky floors, visible trash, and bags of soiled linens and incontinence products left on the ground, while housekeeping leadership noted that the hallway cleaning machine was broken.
The facility failed to provide consistent ADL care, including bathing, grooming, oral care, shaving, and nail care, to multiple dependent residents as required by their assessments and care plans. Several cognitively intact residents reported not receiving showers for extended periods despite being scheduled for twice-weekly showers, and were observed with oily hair, body odor, and unkempt appearance, while documentation either showed showers as completed or contained long gaps with no entries and no recorded refusals. Other residents with dementia, cirrhosis, Parkinson’s disease, ALS, and hospice status were repeatedly observed with long, dirty fingernails, unshaven faces, oily skin, dry, itchy skin, and teeth coated with debris, even though they were fully dependent on staff for ADLs. Staff interviews revealed that heavy care assignments sometimes led to showers not being done, that there was confusion over whether CNAs, nurses, or social services were responsible for nail care and hair appointments, and that refusals and missed showers were not consistently documented as required by facility policy.
The facility failed to follow physician orders and professional standards for wound care and lab services. A resident with a recent toe amputation had no wound dressing orders in place, and an LPN changed the dressing only when the resident requested it, contrary to policy requiring prompt physician orders and scheduled wound care. Another resident with cellulitis and lymphedema had a leg dressing ordered to be changed on a set schedule and PRN when saturated or dislodged, yet observations showed a saturated, partially detached dressing over multiple days with no documented scheduled or PRN changes. A third resident with multiple comorbidities had STAT UA orders on two days that were not carried out, despite reporting urinary pain and abdominal discomfort; staff acknowledged the urine was simply not obtained and did not implement measures such as straight catheterization that they stated would normally accompany a STAT UA order.
The facility failed to ensure that residents with indwelling urinary catheters had corresponding physician orders for catheter care, as required by its catheter care policy. One resident with neurogenic bladder, bilateral lower extremity impairment, and a Foley catheter had prior catheter care and catheter-change orders discontinued, while the care plan still directed catheter care every shift; updated catheter care orders were not present until later. Another resident with BPH and lower urinary tract symptoms had a care plan calling for catheter care every shift, but no catheter care orders appeared on the physician order sheets during the reviewed period. Staff, including an RN and the DON, acknowledged that all residents with catheters were expected to have catheter care orders in place on admission.
Staff allowed a resident to keep and self-administer three prescribed ophthalmic medications at the bedside without following facility policy requiring an interdisciplinary self-administration assessment and a physician order authorizing self-administration and bedside storage. Record review showed active orders for Ofloxacin, Ketorolac, and Prednisolone eye drops but no self-administration assessment and no order permitting bedside medications. Surveyors repeatedly observed the eye drop bottles on the bedside table, and the resident reported self-administering the drops. In interviews, an RN and the DON acknowledged that residents must be assessed for safe self-administration and have a corresponding physician order, which had not been completed for this resident.
The facility did not follow its own bed-hold policy requiring written notice at the time of transfer for hospitalization. Record review showed that two residents who were discharged to the hospital did not have completed and signed bed-hold notices in their files, despite the policy requiring written notice specifying the bed-hold duration and return information and retention of a signed copy. In interviews, an LPN explained that the discharging nurse should fully complete the bed-hold form, including who was informed and the reason for discharge, and the Administrator stated he expected the notice to be given, completed, and signed before the resident left, but this did not occur for these transfers.
The facility failed to meet professional standards when staff did not obtain required admission and readmission weights for two residents with diagnoses including moderate protein-calorie malnutrition, despite physician orders and a policy requiring admission and weekly weights for new or returning residents. In addition, a resident receiving hemodialysis, with multiple comorbidities including CKD, heart failure, and diabetes, lacked timely physician orders for dialysis access assessments such as monitoring for bruising, bleeding, infection, and checking for thrill and bruit, even though the care plan called for close monitoring of the access site. The resident reported that staff did not perform post-dialysis assessments or check the access site, and leadership interviews confirmed expectations that such orders and assessments should have been in place.
Surveyors found that staff failed to follow speech therapy swallowing and positioning recommendations and did not provide required supervision during meals for two residents with cognitive impairment and dysphagia‑related needs. One resident, assessed as dependent for eating and requiring 1:1 feeding and near‑constant swallow safety supervision, was repeatedly observed lying prone in bed, self‑feeding regular food and thin liquids without staff present, including during episodes of loud coughing and spitting out food. Another resident, needing partial to moderate assistance with eating and having a posted swallowing strategies sign directing upright positioning, small bites, slow rate, and supervision, was observed slumped in bed, eating with fingers and left alone after only tray setup and container opening. In both cases, facility leadership and therapy staff acknowledged that expectations were for upright positioning and protective oversight during meals, which was not provided as observed.
Two residents who required staff assistance for bathing and personal hygiene did not receive scheduled showers due to ongoing shortages of towels and washcloths. Staff across multiple units reported that linen carts and closets were often empty during morning care, leading to delays or missed hygiene care. Despite recent linen purchases and new equipment, inconsistent restocking and limited access to laundry supplies continued to impact residents' ability to receive timely personal care.
Staff did not consistently use required gowns and gloves during high-contact care activities for two residents with wounds and indwelling catheters, despite clear orders and signage. Catheter drainage bags were observed lying on the floor and not placed in privacy bags as required, and staff showed inconsistent understanding of proper procedures. Additionally, a dietary aide transported uncovered plated food on a cart, contrary to facility expectations for food safety.
Staff failed to consistently document and administer tube feedings for a resident with a g-tube, leaving multiple entries blank and lacking explanations for missed administrations or refusals. Additionally, Hydrochlorothiazide was administered to another resident without documenting required blood pressure readings beforehand, despite physician orders and facility policy. Leadership interviews confirmed that documentation and monitoring expectations were not met.
Staff failed to timely transcribe new treatment orders and accurately document wound care for several residents with complex wounds, including pressure ulcers and deep tissue injuries. In multiple cases, wound treatments were not started promptly, documentation was incomplete or missing, and physician orders for devices such as wound vacs were not obtained. These deficiencies were confirmed through record review, observation, and staff interviews.
A resident with severe protein-calorie malnutrition did not have admission and weekly weights obtained as ordered, despite facility policy and clear risk factors. Staff failed to document reasons for missed weights or make further attempts to obtain them, and there was no evidence of consistent monitoring or notification of significant weight changes. This resulted in inadequate oversight of the resident's nutritional status.
A resident with vascular dementia and behavioral disturbances did not receive necessary behavioral health care due to the facility's failure to accurately document behaviors and administer psychotropic medications as ordered. Staff often recorded no behaviors despite reports of aggression, non-compliance, and refusals, and medication records did not match pharmacy deliveries or actual administration. The facility did not follow its own policies for behavior management and medication documentation, resulting in inadequate care.
A resident with dementia and agitation was physically abused by a CMT following a verbal altercation, resulting in visible injuries. Staff accounts conflicted, with some initially reporting the resident as the aggressor, but later statements and interviews indicated the CMT struck the resident multiple times. The facility did not immediately recognize or investigate the incident as abuse, and the resident's allegations and injuries were not promptly addressed according to policy.
A resident sustained scratches to the neck and hand following an altercation with multiple staff members. The facility failed to conduct a thorough investigation, as required by policy, after a CNA reported that a staff member had assaulted the resident. The DON did not interview the resident or staff privately, did not report the new allegation to the Administrator, and did not ensure proper documentation or reporting to authorities. Staff statements were collected in a manner that compromised their reliability, and at least one staff member reported feeling coerced into providing a false account.
A resident with a seizure disorder and complex medical history did not receive nine out of ten prescribed doses of anti-seizure medication due to unavailability, and staff failed to notify the DON or physician or use the e-kit supply as required by facility policy. The resident and family repeatedly requested the medication, but it was not provided until several days later, with no clear communication or timely intervention from staff.
The facility failed to ensure residents were free from significant medication errors, including entering and administering a lower dose of Depakote than ordered for a resident after hospital admission, and crushing delayed release Depakote tablets for two residents against manufacturer and pharmacy recommendations. One resident was hospitalized with a low therapeutic level of the medication, and staff interviews confirmed that proper procedures and policies were not followed.
A CNA used profanity while on a personal cell phone during feeding assistance to a resident with severe cognitive impairment, violating the resident's dignity. Four other residents reported staff frequently using phones during care, which they found disrespectful. Facility staff confirmed that personal cell phone use during care is against policy, and recent training on this issue was not attended by the CNA involved.
The facility failed to maintain food temperatures at a safe level, with several residents reporting cold meals. Observations showed that the tray cart was not consistently plugged in, leading to food temperatures below the required 120 degrees Fahrenheit. Staff interviews revealed a lack of communication and training on maintaining food temperatures during meal service.
The facility failed to date opened food packages and maintain cleanliness in dining areas and kitchen equipment. Observations revealed undated food items, dead roaches in dining areas, and unclean steam table wells. Staff interviews indicated a lack of adherence to cleaning protocols and food labeling responsibilities.
The facility failed to maintain safe and appetizing food temperatures, with hot food items not reaching the required 135°F. Observations showed significantly lower temperatures for various food items, and no temperatures were logged for a lunch meal. Residents expressed dissatisfaction with food temperatures, and the Dietary Manager and Administrator acknowledged the issue, noting outdated equipment and the need for regulatory compliance.
A resident with diabetes and other health conditions did not receive prescribed medications, Farxiga and Trulicity, for several days due to communication failures between the facility staff and the pharmacy. The DON acknowledged the oversight, noting that the pharmacy required approval for the medications, which was delayed, and the nurses failed to notify the pharmacy or the DON about the unavailability of the medication.
A resident with severe cognitive impairment and a history of aggressive behavior physically assaulted other residents, leading to a deficiency in protecting residents from abuse. Despite having a care plan for behavior management, the facility failed to implement effective interventions, resulting in harm to other residents. Staff interviews indicated challenges in managing the resident's unpredictable aggression, especially with limited staffing.
A facility failed to timely complete pre-admission screenings and incorporate PASARR Level II recommendations into a resident's care plan. The resident, with a history of schizophrenia and other conditions, was admitted without necessary evaluations. The care plan lacked a behavioral support plan and did not address socialization needs, leading to management challenges due to the resident's history of incarceration and trauma.
A facility failed to provide necessary behavioral health care services for a resident with a history of schizophrenia and psychosis, leading to multiple incidents of verbal and physical aggression. Staff were not informed on how to handle the resident's escalating behaviors, and the care plan lacked detailed interventions. Interviews revealed staff were not given instructions on managing the resident's behaviors, contributing to the facility's failure to meet the resident's psychosocial needs.
A resident's credit card was misappropriated by two CNAs who used it to purchase food from a local restaurant. The incident occurred after the resident's adult child, also a resident, accidentally left the card at a vending machine. The facility's investigation confirmed the unauthorized use, leading to the termination of the involved CNAs.
Misappropriation of Resident Funds by Facility Staff at Casino
Penalty
Summary
The deficiency involves the misappropriation of a resident’s personal funds by facility staff. Record review of the resident’s personal bank statement for November 2025 showed multiple withdrawals using the resident’s debit card at River City Casino, totaling $1,927.00, with individual withdrawals of $1,009.00, $709.00, and $209.00. A transactions report from the bank, obtained by the Town and Country Police Department, documented ATM withdrawals and attempted withdrawals at the casino using the resident’s debit card, including a transaction that exceeded the card limit. Still photos and video from the casino, provided to the police, showed the Housekeeping Supervisor and a CNA entering the casino, walking to a car, and later driving away around the time of the fraudulent ATM transactions. Police investigative reports and interviews further linked the staff members to the use of the resident’s debit card. In a police interview, the CNA confirmed that the driver’s license photo used at the casino blackjack table was his/hers and acknowledged being at the casino with the Housekeeping Supervisor. The CNA stated that the Housekeeping Supervisor asked him/her to retrieve a Capital One card from the car and withdraw $1,000, and that the Housekeeping Supervisor later went to the ATM and withdrew more money. The CNA reported that the Housekeeping Supervisor became stressed afterward and said he/she needed to put money back into his/her mother’s account, and that the Housekeeping Supervisor provided the PIN for the card to the CNA. The CNA identified both him/herself and the Housekeeping Supervisor in the still photos from the casino video footage. In contrast, during an internal interview with the Administrator, the Housekeeping Supervisor denied taking money out of the ATM or seeing the CNA take money out, despite the external evidence placing both staff at the casino during the time of the unauthorized withdrawals from the resident’s account.
Failure to Obtain and Administer Ordered Medications for Two Residents
Penalty
Summary
The facility failed to ensure timely receipt and administration of physician-ordered medications, resulting in multiple missed doses for two residents. For one resident with diagnoses including lung disease, schizophrenia, anxiety, bipolar disorder, insomnia, and depression, the physician ordered cariprazine 4.5 mg once daily upon the resident’s readmission. The order was verified and faxed to the pharmacy, and the medication appeared on the MAR; however, documentation throughout late January and February repeatedly showed the drug as “on order” or “unavailable,” with no evidence that the medication was actually administered. The January MAR reflected 7 of 7 missed administration opportunities, and the February MAR showed 24 of 28 missed administration opportunities for cariprazine. Progress notes for this resident documented behavioral issues during the same period, including difficulty sleeping, frequent use of the call light, yelling that disturbed other residents, inability to be easily redirected, and a resident-to-resident altercation that led to psychology and psychiatry consults. Despite the ongoing unavailability of the antipsychotic medication, there were no documented notifications to the physician regarding the missed doses. A pharmacy representative later stated that the pharmacy had not received a prescription for cariprazine from the facility in January following the resident’s readmission and that the next documented dispensing of the medication did not occur until March, when a 14‑day supply was sent. For a second resident with alcoholic cirrhosis and hepatic encephalopathy, the MAR contained an order for rifaximin 550 mg twice daily for 14 days, but there was no documentation that the medication was administered for the entire ordered period. The pharmacy representative reported that rifaximin was not sent because it required a $1600 out‑of‑pocket payment and was not covered by the resident’s health plan, and that payment from either the facility or the resident was needed. A nurse practitioner stated that nursing staff had informed them that the medication was not covered and asked about a less expensive alternative; the nurse practitioner responded that the rifaximin needed to be dispensed and was not informed that the medication was not being administered. The administrator later stated he was unaware the resident had not received rifaximin and that, in general, staff were expected to notify leadership about missing medications rather than continue to document non‑administration.
Failure to Post DHSS Abuse Hotline and Ombudsman Contact Information in Visible Locations
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to post required contact information for the Missouri Department of Health and Senior Services (DHSS) Elder Abuse and Neglect Hotline and the State Long-Term Care Ombudsman program in visible locations. During observations conducted over multiple days, surveyors noted that no DHSS Abuse and Neglect hotline numbers or Ombudsman contact information were posted in the elevators, on Terrace 2, on the middle hall double doors of Terrace 3, on 3 Short, on 3 Long, or on the Loop. Instead, only corporate compliance contact information was posted in several of these areas. In the front lobby, a bulletin board sign instructed individuals who suspected abuse or neglect to contact the Administrator and listed the Administrator’s phone number, but did not include the DHSS hotline. Outside the Social Worker’s office, a Resident Rights poster included the Ombudsman’s contact number only on a small label approximately 1 inch by 2 5/8 inches, and there was no DHSS hotline number observed there. During a resident council meeting interview, all eight residents present stated they were not aware of the Ombudsman program and confirmed that information about the program was not posted. One resident asked for the correct spelling of the advocacy agency, further indicating unfamiliarity. In a subsequent interview, the Administrator reported that there should be signs for the hotline number by the business office, by the stairwell near Terrace 2, and near the bird cages, but he was only aware of those locations and could not confirm broader posting. He also stated he would need to see the print used for the Ombudsman contact number but would expect it to be large enough for residents to see. These observations and interviews showed that the facility did not adequately post the required State agency and advocacy group contact information, including the DHSS Elder Abuse and Neglect Hotline and Ombudsman program details, in a manner visible and accessible to residents.
Failure to Maintain Clean, Homelike Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and homelike environment in resident rooms and common areas, as required by its own policies. For one resident with osteomyelitis, muscle weakness, unsteady gait, and a need for assistance with personal care, surveyors repeatedly observed an IV pole with thick, crusted yellow dried liquid on the bottom and wheel coverings over several days. The same resident’s fitted bed sheet had maroon and dark brown stains and smears, crumbs were present along the baseboards and behind the dresser, and the resident’s clothing was stored in a clear trash bag. The resident reported that the sheets had never been changed since admission and described the room as filthy, stating the crusted liquid had been on the IV pole since it was brought into the room. Another resident, admitted with cellulitis of the left lower limb and lymphedema, was found over multiple days to have used, stained towels in the corner of the room and used washcloths and towels on the bathroom floor. A grocery bag full of trash was tied to the nightstand, and the fitted bed sheet had brown smears and yellow stains. This resident stated that sheets had never been changed since admission, that staff said they would change the sheets but did not follow through, and that towels in the room had been left by the Wound Nurse the prior week. The resident indicated a desire to clean the room personally but was unable to do so. Staff interviews showed inconsistent understanding of responsibilities: CNAs reported sheets were changed on shower days and clothing should be in closets, while housekeeping staff stated nursing changed sheets and that towels and trash should be removed during room cleaning, with medical equipment cleaning referred to supervisors. Additional observations documented unclean and poorly maintained common areas and equipment. On the 3rd floor terrace, the fire extinguisher cabinet had a large, unidentifiable white stain on multiple dates, and shower rooms contained wet towels on the floor and stained washcloths left in sinks and stalls over repeated observations. The elevator floor had dark, sticky stains on several days, with residents’ and staff’s shoes audibly sticking, and nearby walls and artwork had unidentifiable red splatter and large white stains. The 3rd floor dining room had multiple cracked or broken double windows, some unable to close fully, and one window partially covered by a large piece of cardboard; a handrail outside a resident room was loose and moved when touched. A resident room was repeatedly observed with dirty floors, trash wrappers, and a large dust-like splatter in the bathroom. The loop main hallway was repeatedly noted to have strong odors of urine, sweat, and bowel movement, sticky floors, visible trash, an open dirty linen cart emitting odor, and bags of visibly soiled linens and incontinence products on the ground. The Director of Housekeeping stated housekeepers were responsible for resident rooms and floor technicians for hallways and room floors, and acknowledged the hallway cleaning machine was broken, while the Administrator and DON stated their expectation that rooms, hallways, linens, and equipment be clean and properly stored.
Failure to Provide Consistent Bathing, Hygiene, and Nail Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate activities of daily living (ADL) care, including bathing, personal hygiene, oral care, shaving, and nail care, as required by residents’ assessed needs and facility policy. The facility’s ADL policy required that residents’ abilities in ADLs not deteriorate unless decline was unavoidable, and that residents unable to carry out ADLs receive necessary services to maintain grooming and personal and oral hygiene. Multiple cognitively intact residents reported not receiving showers or adequate hygiene despite documentation indicating showers or baths were provided, and there was no documentation of refusals or unavoidable reasons for missed care. Staff interviews revealed inconsistent understanding of responsibilities for nail care and grooming, and acknowledgment that heavy care assignments sometimes resulted in showers not being completed. One resident with osteomyelitis, diabetes, and a PICC line was documented as having received several showers, yet was observed with long facial hair, odor, and reported never having had a shower because staff would not remove a foot dressing or cover the PICC line. Another resident with ALS, muscle wasting, dysphagia, and full dependence for ADLs was scheduled for showers twice weekly but reported not having had a shower for the entire month, feeling dirty, and wanting hair washed; staff confirmed that heavy care on the hall sometimes led to showers not being done. A resident with a gastrostomy and history of sepsis, dependent for bathing, had long gaps of 6–18 days without documented showers or baths, appeared with oily skin and disheveled hair, and stated they had not received a shower in weeks and were told equipment was not working or lifts were not charged, while staff were unaware of any non-functioning lifts and there was no documentation of refusals. Additional residents with ADL self-care deficits and dependence on staff also lacked appropriate bathing and hygiene. One resident with cirrhosis and encephalopathy reported never receiving a shower or hair wash since admission, only wipe-downs, and remained with very dry skin and oily, stringy hair; staff later stated a shower chair was available on another floor despite the resident being told none was available. Another resident with dementia, stroke, and on hospice care was documented by hospice as receiving bed baths, yet was repeatedly observed with an unshaven face, long fingernails with dark matter underneath, oily face, and white flakes in neck folds, and later only partially shaved with nails still long and dirty. A newly admitted resident with severe cognitive impairment and dependence for bathing and oral hygiene had no January shower documentation and was observed with teeth caked with yellow matter and fingernails with brown matter underneath. The deficiency also included failures in nail and grooming care for several residents who required staff assistance. One resident with Alzheimer’s disease, chronic kidney disease, depression, and Parkinson’s disease, who required moderate assistance for personal hygiene, was repeatedly observed with long, jagged fingernails and requested nail care, while a CNA stated nurses were responsible for trimming nails and was unsure where to find nail files. Another resident with Alzheimer’s disease and muscle weakness, dependent on staff for hygiene, was observed multiple times with long, jagged nails and matter underneath, with staff indicating that either the nurse or hospice nurse could trim nails. A resident with Parkinson’s disease and severe cognitive impairment, fully dependent on staff, was observed on multiple days with long, oily hair, an unkempt beard, and uneven, dirty nails. Interviews with CNAs, nurses, the regional nurse, DON, and administrator showed conflicting statements about who was responsible for hair appointments and nail trimming, and confirmed expectations that residents receive showers or bed baths at least twice weekly and that refusals be documented, which did not consistently occur. Overall, the survey findings showed that despite policies and care plans requiring regular bathing, grooming, and nail care, multiple residents did not receive showers, bed baths, shaving, or nail care as needed or requested, and documentation did not support refusals or unavoidable reasons for missed care. Residents reported feeling dirty, embarrassed, or forgotten, and observations repeatedly showed oily hair, unshaven faces, long and dirty fingernails, and inadequate oral hygiene. Staff acknowledged workload issues and demonstrated inconsistent understanding of roles and documentation requirements, contributing to the failure to ensure residents received appropriate ADL care in accordance with their needs and the facility’s own policy.
Failure to Follow Wound Care and Laboratory Orders per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional standards, and facility policies for wound care and laboratory services. One resident with peripheral vascular disease and diabetes, who had all toes amputated on the left foot due to osteomyelitis, had no physician orders for left foot wound dressing changes from admission through early January. The resident reported always having to ask staff to change the dressing. An LPN confirmed there were no wound care orders and stated that dressing changes were done only when the resident requested them. The facility’s wound policy required obtaining treatment orders in the absence of existing orders and providing wound care per physician orders, but this was not followed for this resident’s post‑amputation foot wound. Another resident with cellulitis of the left lower limb and lymphedema had a physician order for left calf wound care specifying cleansing, application of methylene blue foam, abdominal pads, gauze wrap, and tape, to be changed three times weekly and PRN if saturated, soiled, or dislodged. Record review showed a scheduled dressing change was not documented as completed on a specific date, and no PRN dressing changes were documented over several days. On two separate observations, the resident was seen with an undated left leg dressing that was saturated with serous drainage and with the wrap falling off, requiring the resident to place absorbent materials (a bed pad, then a pillowcase) under the foot to contain the drainage. Interviews with nursing staff and a wound physician confirmed the expectation that dressings be changed as ordered and when wet or dislodged, which did not occur in this case. A third resident, cognitively intact with multiple comorbidities including renal failure, diabetes, and hyponatremia, had STAT orders for a UA with reflex to culture on two consecutive days, but the urine specimen was not obtained as ordered. The resident reported pain with urination and lower abdominal pain, stated they had not completed a urine test, and had not urinated on one of the observation days. An LPN acknowledged that urine had not been obtained and that the resident was not refusing. Subsequent orders for laboratory tests, including urine culture, were entered, and staff reported they were in the process of collecting labs and that normally a STAT UA should include straight catheterization if needed, which had not been done. Documentation later showed the UA was eventually completed days after the initial STAT orders, and interviews with nursing leadership indicated they were unaware of the missed and delayed UA and related hydration issues, despite facility policy requiring timely provision and follow‑up of ordered laboratory services. Overall, the facility did not follow its own Wound Treatment Management and Laboratory Services and Reporting policies, as residents did not receive wound care and laboratory testing in accordance with physician orders, professional standards, and stated expectations for timely treatment and documentation.
Lack of Physician Orders for Catheter Care for Residents With Indwelling Urinary Catheters
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents with indwelling urinary catheters had physician orders that included catheter care instructions, as required by facility policy. The catheter care policy, revised 8/1/25, stated that residents with indwelling catheters would receive catheter care every shift and as needed, drainage bags would be emptied when half-full or every three to six hours, and drainage bags would be kept below bladder level. For one resident with mild cognitive impairment, high blood pressure, kidney failure, neurogenic bladder, bilateral lower extremity impairment, and use of a wheelchair, the electronic physician orders in November 2025 showed discontinuation of orders for monthly Foley catheter and drainage bag changes, catheter care, and catheter privacy covering. The resident’s quarterly MDS still documented an indwelling urinary catheter, and the care plan in use during the survey included a focus on Foley catheter care with an intervention to provide catheter care every shift. Despite the care plan, the resident’s physician orders did not include catheter care until new orders were entered in January 2026 for Foley catheter to gravity drain, catheter care every shift, weekly catheter anchor changes, and use of a leg bag when out of bed. Observations over multiple days showed the resident in an electric wheelchair with the catheter drainage bag hanging from the right armrest. For another resident with a diagnosis including benign prostatic hyperplasia with lower urinary tract symptoms, the care plan identified the presence of a urinary catheter and directed catheter care every shift, but physician order sheets from 12/31/25 through 1/3/26 contained no catheter care orders. In interviews, an RN and the DON stated that all residents with urinary catheters were expected to have catheter care orders in place, and that such orders should be entered on admission, confirming that the absence of these orders for two residents did not meet facility expectations.
Unauthorized Self-Administration and Bedside Storage of Ophthalmic Medications
Penalty
Summary
Facility staff failed to follow its policy on resident self-administration of medications by allowing a resident to keep and self-administer multiple ophthalmic medications at the bedside without the required assessment or physician order. The facility’s policy, revised 8/1/25, states that residents may only self-administer medications after an interdisciplinary team determines which medications can be safely self-administered, with consideration of the resident’s physical and cognitive abilities, understanding of medication instructions, and ability to store medications safely. The policy also requires documentation of the self-administration assessment in the medical record, a physician order authorizing self-administration and bedside storage, and staff reporting of any unauthorized medications found at the bedside. Record review for one resident showed active physician orders for Ofloxacin 0.3% ophthalmic solution, Ketorolac Tromethamine 0.5% solution, and Prednisolone acetate 1% ophthalmic suspension, each ordered four times daily for cataract-related treatment, but no orders authorizing self-administration or bedside storage of these eye drops and no completed self-administration assessment in the medical record. On multiple observations, surveyors saw three eye drop bottles (Ofloxacin, Ketorolac, and Prednisolone) on the resident’s bedside table, and the resident stated that they administered the eye medications themself. In interviews, an RN and the DON confirmed that facility practice requires a management-conducted self-administration assessment and a physician order permitting self-administration and bedside storage, which were not present for this resident.
Failure to Provide Required Bed-Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notices to residents or their representatives at the time of transfer for hospitalization, as required by its Bed Hold Notice Upon Transfer policy dated 8/1/25. The policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would give written notice specifying the duration of the bed-hold policy and information about return to the next available bed, and that a signed and dated copy of this notice would be kept in the resident’s file. Record review for Resident #166 showed a discharge to the hospital on [DATE] with no completed and signed bed-hold notice for 10/16/25. Record review for Resident #177 showed a discharge to the hospital on [DATE] with no completed and signed bed-hold notice for 12/22/25. During interview, LPN K stated that the discharging nurse should document on the bed-hold form whom they spoke with regarding the resident’s discharge and the bed-hold policy, and that the reason for discharge and all sections of the form should be completed. In a separate interview, the Administrator stated he would expect bed-hold notices to be given to the resident or resident representative before the resident leaves the facility and that the form should be filled out and signed. Despite these expectations and the written policy, the records for the two hospitalized residents lacked the required completed and signed bed-hold notices.
Failure to Obtain Ordered Weights and Dialysis Access Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards by not obtaining ordered weights for two residents and not securing timely physician orders for hemodialysis assessments for another resident. For one resident admitted with diagnoses including moderate protein calorie malnutrition, dementia, seizures, and muscle weakness, the physician ordered weekly weights from admission for four weeks, then monthly. The facility’s weight monitoring policy required weights on admission and weekly for four weeks for new admissions. Record review showed weights documented on two dates after admission, but no admission weight was recorded. The resident’s care plan identified a nutritional problem with moderate protein malnutrition and dysphagia and included an intervention to monitor weight as indicated, but the admission weight was missing. For a second resident with an initial admission, subsequent discharge, and readmission, diagnoses included dementia, muscle weakness, intellectual disabilities, schizoaffective disorder, moderate protein calorie malnutrition, dysphagia, and difficulty walking. There was an order for weekly weights from admission for four weeks, then monthly. The care plan identified a nutritional problem with a goal to maintain adequate nutritional status as evidenced by maintaining weight and included providing and serving diet as ordered. Weight records showed values on the initial admission date and subsequent dates, but there was no weight documented at the time of readmission, despite staff interviews indicating that residents should be weighed on admission and upon return from the hospital to establish a new baseline. The facility also failed to ensure physician’s orders for hemodialysis-related assessments were in place for a resident receiving dialysis. This resident was cognitively intact and had multiple diagnoses including anemia, heart failure, hypertension, kidney failure, diabetes, hyperlipidemia, anxiety, depression, bipolar disorder, and asthma, and received dialysis. The care plan for dialysis focused on minimizing complications and included interventions such as checking and changing the dressing at the access site daily, monitoring vital signs before and after dialysis, monitoring and documenting edema and weight gain, and monitoring for signs and symptoms of infection and renal insufficiency. The physician orders included renal care on specific days, maintaining a clean, dry, intact dialysis dressing, and, starting on a later date, orders to monitor the access site for bruising, bleeding, infection, and to assess for thrill and bruit every shift. Review of order history showed no prior physician orders to monitor the access site or assess for thrill and bruit before that later date. The resident reported that staff did not complete assessments after dialysis and had never checked the bruit and thrill, and the DON stated she expected such orders and assessments to be in place but could not explain why they were not ordered earlier.
Failure to Follow Speech Therapy Swallowing and Supervision Recommendations During Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a safe, hazard‑free environment and adequate supervision during meals for residents with specific speech therapy swallowing and positioning recommendations. Facility policies on Activities of Daily Living and Assisted Nutrition and Hydration required care and services to be based on comprehensive assessments, including appropriate assistance with eating and adherence to therapeutic diets and monitoring needs. Despite these policies, staff did not consistently follow speech therapy guidance or provide the ordered level of supervision and positioning during meals for two residents with cognitive impairment and dysphagia‑related needs. For one resident with mild cognitive impairment, neurogenic bladder, malnutrition, cerebellar ataxia, dysphagia, muscle weakness, and a documented dependence on staff for eating, the MDS showed the resident was dependent with eating and receiving speech therapy. A speech therapy evaluation documented that this resident required 1:1 feeding assistance, supervision for swallow safety 91–100% of the time at meals, and skilled ST three times a week to address swallowing and communication deficits. Physician orders included a regular diet with thin liquids and nutritional supplements. However, on multiple observations, the resident was found lying prone in bed on his/her stomach, self‑feeding regular meals and liquids without staff present or monitoring. On one occasion, staff entered only after the meal to remove the tray, leaving food pieces under the resident; on another, the resident coughed loudly and harshly and spit out food while continuing to eat unassisted. The Director of Therapy and the speech therapist both stated they expected the resident to be up in a chair for meals when possible and to have oversight if eating on his/her stomach, and the Administrator and DON stated they expected staff to provide protective oversight during meals when ordered. For a second resident with moderate cognitive impairment, stroke, dementia, and anxiety, the MDS indicated a need for partial to moderate assistance with eating. The care plan identified a potential nutritional problem related to dementia and directed staff to provide dining assistance such as tray setup, cutting food, identifying items, and feeding as needed. A swallowing strategies sign posted in the resident’s room instructed staff to assist with cutting food and tray setup, provide supervision at mealtimes, maintain an upright position during meals, and ensure small bites, slow rate, and alternating food and liquids. Despite these instructions, surveyors observed the resident slumped in bed, eating ground sausage with fingers, with the meal tray on a bedside table and no staff supervision. On another observation, the ADON and a CNA positioned the resident in bed and set up the meal but then left the room, after which the resident again ate with fingers without supervision, while the swallowing strategies sign remained posted. A CNA, the speech therapist, and the DON each confirmed that staff were expected to follow the posted swallowing strategies, keep the resident upright, and supervise the resident during meals, which was not done during the observed meals.
Failure to Provide Timely Personal Hygiene Due to Linen Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene and bathing, to residents who required such care. Two residents who were dependent on staff for bathing and personal hygiene did not receive showers as scheduled, with one resident reporting not having had a shower for over two weeks. Both residents expressed that the lack of clean towels and washcloths contributed to missed showers and delays in personal care. Staff interviews confirmed that towel and linen shortages were a recurring issue, impacting their ability to provide timely hygiene care. Observations and interviews revealed that multiple units, including the Memory Care unit, 500-hall, and rehab hall, experienced shortages of towels and washcloths. Linen carts were often not restocked until late morning or afternoon, and clean linen closets were found empty during morning care times. Staff reported having to wait for laundry to be completed or for carts to be restocked, sometimes resulting in residents not receiving showers or having their beds made. Disposable wipes were available in limited quantities, but staff primarily relied on regular linens, which were insufficient to meet resident needs. The facility's laundry and linen management practices contributed to the deficiency. Staff described inconsistent restocking schedules, locked laundry rooms, and reliance on emergency supplies or family-provided items when shortages occurred. Despite recent purchases of linens and new equipment, staff and residents continued to report inadequate access to necessary supplies for personal care. The deficiency was further evidenced by direct resident complaints, staff interviews, and observations of empty linen storage areas during surveyor visits.
Failure to Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Staff failed to follow established infection prevention and control protocols, specifically Enhanced Barrier Precautions (EBP), during high-contact care activities for two residents with wounds and indwelling catheters. Despite clear physician orders and care plans requiring the use of gowns and gloves during such activities, observations revealed that staff only donned gloves and omitted gowns while performing wound care and transfers. EBP signage and supply bins were present, but staff did not consistently adhere to the required use of personal protective equipment (PPE) as outlined in facility policy and CDC/CMS recommendations. Additionally, the facility did not maintain proper management of catheter drainage bags. On multiple occasions, a resident's catheter drainage bag was observed lying on the floor and not placed in a privacy bag, contrary to facility policy. Interviews with staff indicated a lack of clarity regarding the location of privacy bags and inconsistent understanding of proper catheter bag handling, despite recent training. Staff acknowledged that drainage bags should not touch the floor and should be covered, but these practices were not followed during the survey. The facility also failed to ensure food safety standards were met when a dietary aide transported uncovered plated food on a cart via the elevator. The administrator confirmed that food should be covered during transport, but observations showed several plates without lids. These lapses in infection control and food safety practices were directly observed and confirmed through staff interviews and record reviews.
Failure to Document and Administer Tube Feedings and Blood Pressure Monitoring
Penalty
Summary
Staff failed to accurately document and administer tube feedings for a resident with a gastric tube, who had a history of high blood pressure, diabetes, traumatic brain injury, and was dependent on staff for all activities of daily living. The resident's care plan included interventions for unplanned weight loss and required tube feedings and water flushes as ordered by the physician. However, multiple entries on the treatment administration record (TAR) were left blank, with no documentation to indicate whether the tube feedings or flushes were administered or refused. Progress notes indicated occasional refusals and disconnections by the resident, but there was no consistent documentation explaining the missed administrations or refusals, as confirmed by the registered dietician who relied on these records to monitor the resident's nutrition. Another deficiency involved the administration of Hydrochlorothiazide, an antihypertensive medication, to a resident with moderate cognitive impairment and a diagnosis of hypertension. The physician's order specified that the medication should not be given if the systolic blood pressure was less than 100, and the care plan required monitoring for side effects and effectiveness. Despite this, the medication administration record showed the medication was given daily without any documentation of the resident's blood pressure prior to administration. Interviews with nursing staff and the nurse practitioner confirmed that blood pressure readings were not consistently documented before giving the medication, even though it was expected per facility policy and physician order. Interviews with facility leadership, including the regional nurse consultant, corporate nurse, and administrator, confirmed expectations that staff should document all treatments and medications administered, as well as vital signs when required by physician orders. The facility's policy required documentation of all assessments, observations, and services at the time of service or by the end of the shift, but this was not consistently followed in the cases reviewed.
Failure to Timely Transcribe Orders and Accurately Document Wound Care
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for multiple residents, as evidenced by untimely transcription of new treatment orders and inaccurate documentation of treatments. For one resident with a stage 2 pressure ulcer, staff did not consistently document wound care treatments on the Treatment Administration Record (TAR), with several missed entries and no explanation for delays in starting prescribed treatments. Additionally, after a surgical procedure resulting in a wound vacuum being placed, there was no physician order for the wound vac, and documentation of wound care remained incomplete. Another resident admitted with multiple pressure injuries, including a stage 4 ulcer and deep tissue injuries (DTIs), did not have all wounds identified or documented upon admission. The admitting nurse failed to document the presence of DTIs, and treatment orders for wounds were not initiated until several days after admission, with no documentation that the physician was notified of the delay. Hospital discharge instructions for wound care were not promptly transcribed or implemented, and the required skin assessment lacked complete wound descriptions. A third resident with a stage 4 pressure ulcer and additional wounds also experienced lapses in treatment documentation. Several wound care treatments and g-tube flushes were not documented as administered, and there was no record explaining the missed treatments or whether the physician was notified of delays in starting new orders. Interviews with facility staff confirmed that nurses were responsible for entering and documenting orders, and that documentation should occur at the time of service, but these practices were not consistently followed.
Failure to Monitor Nutritional Status and Obtain Required Weights
Penalty
Summary
A deficiency occurred when staff failed to monitor a resident's nutritional status and the effectiveness of interventions by not obtaining admission and weekly weights as ordered for a resident diagnosed with severe protein-calorie malnutrition. The facility's policy required a comprehensive nutritional assessment upon admission, including obtaining a weight within the first 24 hours and weekly weights for four weeks, but these were not consistently completed. Documentation repeatedly showed weights were not obtained, with no explanation or evidence of further attempts to secure the required measurements, despite clear orders and the resident's high risk status. The resident in question had a history of vascular dementia with behavioral disturbance and was admitted with severe chronic malnutrition, as evidenced by severe fat and muscle loss and intake of less than 75% of estimated needs. Hospital records and facility documentation indicated variable oral intake, with the resident consuming most of the prescribed nutritional supplement but less than 50% of meals. Despite these concerns, the facility failed to document weights at admission and on a weekly basis, and there was no documentation of why weights could not be obtained or of any follow-up actions to address the missed weights. Interviews with facility staff, including the registered dietician, LPNs, nurse practitioner, and regional nurse consultant, confirmed expectations that weights should be obtained upon admission and weekly thereafter for new admissions, especially for residents at nutritional risk. However, the records showed ongoing failures to obtain and document weights, and staff were not notified of significant weight changes. The lack of consistent weight monitoring and documentation for this resident with severe malnutrition constituted a failure to follow facility policy and ensure adequate monitoring of nutritional status.
Failure to Provide Necessary Behavioral Health Services and Accurate Medication Administration
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with vascular dementia and behavioral disturbances. The resident was admitted with a history of violent and explosive behaviors, including physical aggression toward staff and other residents, paranoia, delusions, and non-compliance with care. Despite these documented behaviors, facility staff failed to accurately document the resident's behaviors, often recording 'no behaviors' on monitoring tools, even when there were reports of refusals, hitting, disrobing, and attempts to ambulate without assistance. Interviews with CNAs and LPNs confirmed the presence of aggressive and non-compliant behaviors, but these were not reflected in the official documentation or behavior monitoring records. The facility also failed to administer psychotropic medications as ordered and did not accurately document medication administration or refusals. Medication Administration Records (MARs) indicated that medications such as Rexulti, Olanzapine, Valproic Acid, Lexapro, and Mirtazapine were documented as administered, but pharmacy records and medication counts revealed discrepancies. For example, the supply of Rexulti and Olanzapine on hand did not match the number of doses documented as given, and staff interviews revealed that some medications were not available or not administered as ordered. Additionally, there was a lack of documentation regarding medication refusals, despite staff and CNA reports that the resident sometimes spit out or refused medications. The facility's policies required clear and accurate documentation of behaviors, medication administration, and refusals, as well as the development and regular review of a behavioral management plan. However, the interdisciplinary team did not ensure that the resident's behaviors were properly identified, documented, or addressed in the care plan. The lack of accurate documentation and failure to administer medications as ordered resulted in the resident not receiving necessary behavioral health care and services, as required by facility policy and regulatory standards.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
Facility staff failed to protect a resident with dementia, restlessness, agitation, and cognitive communication deficits from physical abuse. On the day of the incident, a certified medication technician (CMT) engaged in a verbal altercation with the resident after the resident coughed or pretended to cough on another staff member. The CMT used profanity, called the resident derogatory names, and both parties exchanged threats. The situation escalated when the CMT pushed the resident, who pushed back, leading the CMT to strike the resident around the face and neck, pushing the resident against the wall. Other staff intervened, pulling the resident away, which resulted in the resident falling to the ground. The resident sustained visible injuries to the neck and hand. Multiple staff members were present during the incident, and their accounts varied. Some staff initially wrote statements indicating the resident attacked the CMT, but later interviews and a second statement from one CNA described the CMT as the aggressor, using physical force and continuing to attempt to strike the resident even after the resident was on the ground. The resident reported being assaulted by the CMT and expressed feeling unsafe and distrustful of the staff. Physical evidence of injury was observed and measured by the wound nurse, including scratches on both sides of the neck and on the hand. The facility's abuse policy required immediate protection and investigation of alleged abuse, but the initial response focused on staff statements that framed the resident as the aggressor. The nurse and DON did not specifically ask the resident if they had been assaulted, and the initial staff statements were collected in a group setting, with some staff later reporting feeling coerced to match their accounts. The incident was not immediately reported as abuse, and the resident's allegations and injuries were not promptly or thoroughly investigated according to policy requirements.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an altercation between a resident and several staff members, resulting in the resident sustaining scratches on both sides of the neck and on the left hand. The initial response involved a registered nurse collecting written statements from the involved staff, but these statements were written and read aloud in front of each other, compromising the integrity of the investigation. The following day, a certified nurse aide reported to the Director of Nursing (DON) that their initial statement was inaccurate and provided a new account alleging that a staff member had assaulted the resident. Despite this new information, the DON did not further investigate the incident, did not interview the resident or other staff members privately, and did not inform the Administrator of the revised statement. The facility's own policy required immediate and thorough investigation of any allegations or suspicions of abuse, including private interviews with all involved parties and prompt reporting to the Administrator and relevant authorities. However, the investigation was limited to collecting initial written statements, with no documentation of resident interviews or private staff interviews. The DON also failed to ensure that the new allegation of staff-to-resident assault was reported or investigated according to policy. The Administrator was not made aware of the revised statement or the resident's allegations, and the incident was not reported to state agencies as required. The resident involved had a history of agitation and conflict with the staff member in question, and after the incident, was observed with visible injuries and reported feeling unsafe and distrustful of the staff. Multiple staff interviews revealed inconsistencies in their accounts, with at least one staff member stating they felt coerced into writing a false statement. The facility's failure to conduct a thorough, unbiased investigation and to follow its own abuse reporting policies resulted in a deficient practice affecting at least one resident.
Failure to Administer Prescribed Anti-Seizure Medication and Notify Physician
Penalty
Summary
The facility failed to administer a resident's prescribed anti-seizure medication, Levetiracetam, as ordered by the physician, resulting in nine out of ten missed doses over a five-day period. Documentation in the resident's medical record indicated that the medication was not available to staff, and there was no evidence that the physician or the Director of Nursing (DON) was notified of the missed doses. The facility's medication administration policy required that discrepancies with medication orders or supplies be reported to the nurse manager, and that the e-kit, which contained an emergency supply of Levetiracetam, be used in such situations. However, staff did not utilize the e-kit or follow the notification procedures outlined in the policy. The resident, who had a history of diabetes, stroke, and Moyamoya Disease, had a physician order for Levetiracetam 500 mg twice daily. The resident reported going without the seizure medication for almost a week, expressing fear of experiencing another seizure, especially given a recent diagnosis of a seizure disorder that had previously led to a heart attack. The resident and a family member both reported making multiple requests for the medication and seeking information from facility staff, but were only told that the issue was being addressed, without specifics or resolution until after the missed doses. Interviews with facility staff and pharmacy representatives confirmed that the medication was not administered due to it being unavailable, and that the pharmacy had last delivered a 30-day supply several days prior to the missed doses. Staff acknowledged that the e-kit contained an emergency supply of the medication and that procedures required immediate re-ordering and notification of the DON when medications were missing. Despite these protocols, the necessary steps were not taken, resulting in the resident missing nearly all scheduled doses of a critical medication over several days.
Significant Medication Errors: Incorrect Dosing and Improper Administration of Depakote
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by incorrect medication dosing and improper medication administration practices. One resident was admitted with a hospital order for Divalproex (Depakote) 250 mg three times daily, but the facility entered and administered a lower dose of 125 mg three times daily for six days. This discrepancy was not accompanied by any documentation of a physician order change or justification in the medical record, despite facility policy requiring orders to match hospital discharge instructions unless otherwise directed by a provider. Additionally, staff failed to follow manufacturer and pharmacy recommendations regarding the administration of Depakote delayed release tablets. Multiple residents received their Depakote tablets crushed, despite clear labeling and manufacturer instructions stating that the medication should not be crushed. In one case, a resident who had difficulty swallowing and often refused medication was given crushed Depakote after a physician order was obtained to crush medications. However, the medication card was labeled "do not crush," and the staff did not have a do not crush list available. Another resident also received crushed Depakote due to dietary needs, with the medication administered in pudding. These actions resulted in at least one resident being hospitalized with a low therapeutic level of Depakote, as confirmed by hospital laboratory results. Interviews with staff, including the DON and pharmacist, confirmed that crushing delayed release Depakote is not recommended and can affect the medication's effectiveness. The facility's medication administration policy required staff to administer medications as ordered and in accordance with manufacturer specifications, which was not followed in these instances.
Staff Cell Phone Use and Profanity Violate Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents when a Certified Nurse Aide (CNA) used profanity while on a personal cell phone during feeding assistance to a resident with severe cognitive impairment. This incident occurred in the presence of a Certified Medication Technician (CMT) who did not intervene. The resident, who required partial to moderate assistance for eating due to conditions such as dementia and malnutrition, was unable to respond to questions during an attempted interview. The CNA admitted to using profanity and acknowledged the inappropriateness of using a cell phone while assisting the resident. Additionally, four other residents, all cognitively intact and diagnosed with anxiety and depression, reported issues with staff being on their phones while providing care. These residents expressed that some aides were disrespectful, often using their phones during work hours, and some even wore earphones, ignoring the residents. The residents found this behavior rude and unprofessional, indicating a broader issue with staff conduct and adherence to facility policies. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Director of Nurses (DON), and the Administrator, confirmed that personal cell phone use while providing care is against facility policy. The DON noted that staff had recently received training on cell phone use and customer service, but the CNA involved in the incident was not documented as having attended. The Administrator acknowledged the need for additional education for the staff involved in the incident.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained at a safe and appetizing temperature. Three out of six residents, who ate their meals in their rooms, reported that hot foods were often served cold. Observations revealed that the tray cart, which is designed to keep food warm, was not consistently plugged in during meal service. This resulted in food temperatures falling below the required 120 degrees Fahrenheit, with mashed potatoes and spinach recorded at 108 and 105 degrees Fahrenheit, respectively, and an omelet at 114 degrees Fahrenheit. Interviews with residents and staff highlighted a lack of communication and training regarding the importance of keeping the tray cart plugged in to maintain food temperatures. A resident mentioned that staff would reheat food in the microwave upon request, indicating a workaround for the issue. However, a CNA admitted to not being informed about the necessity of keeping the cart plugged in, and the Dietary Manager confirmed that the cart should remain plugged in during service. The facility's administrator also expressed the expectation that the cart should be plugged in until all trays are served.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not dating opened packages of food. During an observation in the main kitchen, several opened food packages, including brown gravy, bowtie pasta, and spaghetti noodles, were found wrapped in plastic wrap without any dates. This oversight indicates a failure to follow the facility's policy, which requires all opened food items to be sealed, labeled, and dated before being returned to storage. Additionally, the facility did not maintain cleanliness in the dining areas and kitchen equipment. Observations in the 3rd floor kitchenette and dining room revealed dead roaches in drawers and cabinets, along with food crumbs and dried stains. The presence of roaches and bait traps, along with the lack of awareness from staff about these conditions, highlights a significant lapse in maintaining a sanitary environment as per the facility's sanitation policy. Furthermore, the facility failed to properly clean kitchen equipment, specifically the steam table wells. Observations showed dirty, frothy water with food particles in the steam table wells, which were not cleaned before adding clean water and placing food pans. Interviews with staff, including the Dietary Manager and Administrator, revealed a lack of consistent adherence to cleaning protocols, with responsibilities for cleaning and food labeling not being effectively communicated or enforced among staff members.
Deficiency in Maintaining Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that prepared food items were served at a safe and appetizing temperature, as observed during a survey. The internal temperatures of hot food items were not maintained at 135 degrees Fahrenheit or higher, which is necessary to prevent the growth of food-borne pathogens. This deficiency was noted during an observation where the internal temperatures of various food items, such as chocolate pudding, hush puppies, breaded/fried fish, and green beans, were recorded at significantly lower temperatures than required. Additionally, the Tray Line Food Temperature Log showed no recorded temperatures for the lunch meal on the day of observation. Interviews with residents revealed dissatisfaction with the food temperatures, with one resident stating the food was usually cold and another mentioning it was warm but not hot. The Dietary Manager confirmed that food temperatures were taken before serving but were not logged, and expressed an expectation for hot food to be hot and cold food to be cold. The Administrator acknowledged the issue, noting that the insulated food carts were old and might need replacement, and emphasized the importance of meeting regulatory temperature standards.
Failure to Administer Diabetes Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of diabetes medications. The resident, who was cognitively intact and had diagnoses including diabetes, heart failure, and chronic kidney disease, did not receive prescribed medications, Farxiga and Trulicity, for several days. The facility's records showed that these medications were marked as unavailable on multiple occasions, and there were no progress notes explaining the non-administration of Trulicity. The Director of Nursing (DON) acknowledged that the facility failed to administer the resident's Trulicity medication, which was intended for weight loss rather than diabetes. The DON explained that the pharmacy required approval for the medication, which was delayed, and the nurses failed to notify the pharmacy or the DON about the unavailability of the medication. The nurses marked the medication as unavailable and informed the doctor but did not follow up with the pharmacy or the DON. The admission nurse was responsible for verifying orders with the physician, and the Assistant Director of Nursing (ADON) was responsible for auditing admissions. The DON discovered during a medication audit that the pharmacy had approval for Farxiga but did not deliver it to the facility. Additionally, the pharmacy sent only three-day doses instead of the full card, leading to missed doses. The staff did not notify the DON about the medication's absence, and there was a lack of communication between the facility and the pharmacy regarding the medication's delivery and administration.
Resident Aggression Leads to Physical Abuse in LTC Facility
Penalty
Summary
The facility failed to ensure that four residents were free from physical abuse, as evidenced by incidents involving a resident who physically assaulted other residents. The incidents occurred when a resident, who was severely cognitively impaired and had a history of aggressive behavior, hit other residents in the face and stomach. The facility's records showed that the resident had previously exhibited combative behavior towards staff and other residents, and had been sent to the hospital multiple times for evaluation due to aggressive behaviors. The resident's care plan included interventions for behavior management, but there were no new documented behavioral interventions after a certain date, prior to the assault. Staff interviews revealed that the resident's aggressive behavior was unpredictable and difficult to manage, especially when staffing levels were low or when only female staff were present. The resident's aggressive actions were not effectively mitigated, leading to physical harm to other residents. The facility's policy on abuse, neglect, and exploitation was in place, but the implementation of preventive measures and interventions was insufficient to protect residents from harm. The staff's inability to redirect the resident and the lack of effective interventions contributed to the occurrence of physical abuse among residents. The facility's failure to adequately address the resident's aggressive behavior resulted in a violation of the residents' right to be free from abuse.
Failure to Incorporate PASARR Recommendations in Resident Care Plan
Penalty
Summary
The facility failed to ensure timely completion of pre-admission screenings and did not incorporate recommendations from the PASARR Level II determination into the care plan for a resident. The resident, who had a history of chronic kidney disease, diabetes, schizophrenia, and unspecified mood disorder, was admitted without the necessary PASARR Level II evaluation being completed prior to admission. The evaluation, which was completed after admission, identified the need for specific supports and services, including a structured environment, behavioral support plan, and medication therapy, which were not initially included in the resident's care plan. The resident's care plan was found lacking in several areas, including the absence of a behavioral support plan until after the resident's behavior escalated. There was no documentation of assessing and planning for meaningful socialization and recreational activities to prevent isolation, nor was there development of personal supports to prevent isolation in the community. The care plan also failed to include the necessary supports and services identified in the PASARR Level II evaluation, such as monitoring of behavioral symptoms and provision of a structured environment. Interviews with facility staff revealed that the resident was difficult to manage due to a history of incarceration and trauma, which contributed to his/her rigid behavior and difficulty adapting to the facility environment. Staff reported that the resident was not very social and often isolated, and there was a lack of direction on how to manage his/her behavior. The MDS coordinator acknowledged the oversight in the care plan, attributing it to being new to the facility and trying to catch up on care plans. The administrator admitted that the resident's behavioral issues were not promptly addressed in the care plan, as they were focused on managing the immediate situation.
Failure to Address Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being, as evidenced by the lack of staff intervention in managing the resident's escalating behaviors. The resident, who had a history of chronic kidney disease, diabetes, unspecified mood disorder, schizophrenia, and unspecified psychosis, exhibited behaviors such as verbal aggression, hallucinations, and delusions. Despite these behaviors, the facility did not inform staff on how to handle the resident's escalating behaviors, leading to multiple incidents where the resident became verbally and physically aggressive towards staff and other residents. The resident's medical records and progress notes indicated several instances of inappropriate behavior, including sexually inappropriate comments to staff, calling the police over misunderstandings, and using racial slurs and derogatory language towards staff. On one occasion, the resident became agitated, lunged at a nurse, and called 911 multiple times, alleging abuse by staff. Despite these incidents, staff were not provided with guidance on managing or preventing the resident's behaviors, and the care plan lacked detailed interventions for addressing the resident's behavioral issues. Interviews with staff revealed that they were not given instructions on how to manage or prevent the resident's behaviors, leading to feelings of fear and uncertainty. The facility's investigation noted that the resident had a history of incarceration and trauma, which may have contributed to his behavior, but this information was not adequately reflected in the care plan. The lack of a comprehensive care plan and staff training on handling aggressive behaviors contributed to the facility's failure to meet the resident's psychosocial needs.
Financial Misappropriation by Staff Members
Penalty
Summary
The facility failed to protect a resident from financial misappropriation when two staff members wrongfully used the resident's credit card. The incident began when a resident, who is cognitively intact and diagnosed with end-stage renal disease and muscle weakness, allowed their adult child, also a resident, to use their credit card to purchase a soda from a vending machine. The adult child, who is cognitively intact and diagnosed with diabetes and major depressive disorder, accidentally left the credit card at the vending machine. Later, the resident received a bank alert indicating that their credit card was used at a local restaurant without their permission. The facility's investigation revealed that two CNAs used the resident's credit card to purchase food from the restaurant. The resident confirmed the unauthorized use of their card after contacting the restaurant and subsequently reported the card as stolen to the police. Interviews with the involved parties, including the CNAs and the administrator, confirmed the misuse of the credit card by the staff members. The administrator gathered sufficient evidence to determine that the two CNAs were responsible for the unauthorized transaction.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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