Bentleys Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland, Missouri.
- Location
- 3060 Ashby Road, Overland, Missouri 63114
- CMS Provider Number
- 265732
- Inspections on file
- 23
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Bentleys Extended Care during CMS and state inspections, most recent first.
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.
Three residents with cognitive impairment and a history of falls experienced multiple incidents without thorough investigation or consistent implementation of fall prevention interventions. Care plans were not updated to reflect current physician orders, such as the use of soft helmets or floor mats, and staff were often unaware of required interventions due to outdated communication systems. Documentation of falls and follow-up actions was incomplete, and there was no effective process to ensure that new or modified interventions were put in place after each fall.
A resident with multiple medical conditions experienced a broken front tooth and reported pain and difficulty eating, but did not receive timely dental care. After an unsuccessful dental appointment due to transfer issues, no alternative arrangements were made, and the resident later developed a dental abscess treated only with antibiotics. Staff interviews revealed a lack of follow-up and communication, resulting in the resident waiting over a year without appropriate dental intervention.
A resident with Alzheimer's disease and severe cognitive impairment was subjected to alleged physical abuse by a CNA, who was observed yelling and holding the resident against the wall. Despite the incident being reported to the DON, the CNA was not immediately suspended and continued to provide care for several hours. Staff interviews revealed confusion about abuse reporting procedures, lack of timely investigation, and insufficient training on abuse prevention policies.
Staff failed to follow required two-person protocols during Hoyer lift transfers, resulting in a resident being struck in the face and later falling from bed due to missing fall mats, both causing injuries. In addition, staff did not perform required neurological assessments after head injuries, and new aides conducted unsafe transfers without proper training, leading to repeated hazards for a dependent resident with dementia and a history of falls.
A resident with severe cognitive impairment was involved in an incident where a CNA was observed physically restraining the resident and yelling. An RN reported the event to the DON, but the DON did not notify the state agency within the required two-hour timeframe, citing a need for more information and lack of awareness of the policy. Other leadership staff were not informed until hours later, resulting in a failure to promptly report the abuse allegation as required.
The facility did not submit complete and accurate direct care staffing information to CMS for three consecutive fiscal quarters. The Assistant Administrator admitted responsibility for the oversight, acknowledging awareness of the requirement but failing to act. The facility had a census of 47.
The facility failed to maintain resident dignity by allowing staff to use cell phones during care, contrary to policy. Observations showed staff texting while feeding residents and not providing necessary assistance, such as replacing dropped utensils. Residents reported feeling uncomfortable due to staff phone use during care.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. One resident's care plan lacked interventions for weight loss and catheter use, another's did not reflect falls and cognitive decline, and a third's did not address dietary needs and preferences.
The facility failed to provide adequate supervision and assistance to prevent accidents, as observed with residents being propelled in wheelchairs without leg rests, leading to discomfort and potential injury. Staff did not consistently use gait belts during transfers, posing a risk of injury. Additionally, a resident with a history of falls was not properly repositioned in their wheelchair, despite being observed leaning and slouched.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week, as per their staffing policy. Staffing sheets showed multiple days without RN coverage, and the ADON acknowledged the difficulty in securing RNs despite posting requests. The Assistant Administrator expected RN staffing to be covered as required.
The facility failed to maintain accurate records for controlled drugs, with numerous shifts lacking the required dual nurse initials on narcotic count sheets. This non-compliance was observed on multiple medication carts, potentially affecting all residents with controlled substance orders. Staff interviews confirmed the expectation for two staff members to sign off on narcotic counts every shift.
The facility failed to maintain proper storage conditions for medications in the medication room refrigerator, as there was no system or temperature log in place. Medications were stored alongside food items, contrary to facility policy. Staff, including a CMT and an LPN, were unaware of the requirements for temperature monitoring and separate storage of medications and food.
Staff at the facility failed to perform proper hand hygiene during meal service, affecting 15 residents. Observations showed that staff, including an LPN and NAs, did not wash hands or use sanitizer before or after assisting residents with meals, contrary to the facility's policy. Interviews confirmed that staff were expected to follow hand hygiene protocols, but observations indicated non-compliance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with urinary catheters and wounds, as staff did not wear gowns during high-contact care activities. Additionally, infection control standards were not followed during wound care, with an LPN using ungloved hands and uncleaned equipment. The facility also neglected to conduct required TB testing for several residents, as per its policy.
The facility did not offer or administer the pneumococcal vaccine to four residents, despite having a policy requiring assessment and vaccination within thirty days of admission. The ADON confirmed the expectation to offer the vaccine and document refusals, but records showed no documentation of screening or vaccination for residents with conditions like stroke, diabetes, and sepsis.
The facility failed to offer COVID-19 vaccines to four residents, despite having a policy requiring vaccination offers to all eligible individuals. The ADON, responsible for overseeing vaccination documentation, did not ensure that Residents #11, #38, #22, and #14 were screened or vaccinated, as their medical records lacked such documentation. This indicates a lapse in following the facility's vaccination policy.
The facility failed to ensure CNAs received the required 12 hours of annual education, with no training records available for sampled CNAs and CMTs. Interviews revealed a lack of formal tracking or documentation of in-service training, and the ADON admitted to not maintaining a system for tracking these trainings.
A facility failed to promptly notify a physician of a resident's abnormal lab results indicating a UTI, resulting in delayed antibiotic treatment. The resident and their representative were not informed about the UTI diagnosis or new medication orders. Interviews with staff revealed inadequate processes for handling lab results, especially on weekends, and a lack of documentation in the resident's EMR.
The facility failed to provide written notices of transfer/discharge to two residents transferred to the hospital for acute medical reasons, as required by their policy. Interviews with staff, including an LPN and the ADON, confirmed that while other paperwork is sent with residents, the practice of sending transfer/discharge notices had lapsed. The ADON and Assistant Administrator acknowledged the lack of documentation for these notices.
The facility failed to provide written bed hold policy notices to two residents transferred to the hospital, as required by its policy. Interviews with staff revealed that the practice of sending these notices had lapsed, despite expectations from the ADON and Assistant Administrator that they should be provided.
A resident in an LTC facility experienced significant unplanned weight loss and had unhealed pressure ulcers that were not accurately documented in their MDS assessment. The ADON misinterpreted the weight loss question and failed to record the pressure ulcers, focusing instead on the resident's bullous pemphigoid wounds. This resulted in an inaccurate assessment of the resident's health status.
The facility failed to maintain comprehensive care plans for four residents, despite changes in their care needs. Diagnosed with various conditions, these residents did not have updated care plans in the EMR, contrary to facility policy. Staff interviews revealed reliance on verbal instructions due to missing care plans, with the ADON citing an error in care plan creation.
The facility failed to ensure that all CPR-certified staff received training with hands-on practice and in-person skills assessment. Three staff members, including an RN and the ADON, obtained their CPR certification through an online provider, which does not meet regulatory requirements. The facility's policy lacked guidance on this issue, and staffing records showed these staff were often the only CPR-certified personnel scheduled. Interviews revealed a lack of awareness about the specific requirements for CPR certification.
A facility failed to provide proper care by not assessing the appropriate wheelchair size for a resident, resulting in skin irritation and indentations. The resident, with multiple health conditions, was left in the wheelchair for six hours without repositioning, despite complaints of pain. Additionally, another resident's dressing was not dated, leading to uncertainty about when it was applied. These actions reflect a failure to meet acceptable standards of practice in resident care.
Two residents in the facility experienced inadequate foot care, resulting in long nails and dry skin. One resident, with diabetes, had not seen a podiatrist in eight months, while another resident with severe cognitive impairment had refused podiatry care. Staff interviews revealed inconsistencies in documenting and addressing foot care needs, with both CNAs and LPNs responsible for this aspect of care.
The facility failed to follow physician orders for continuous oxygen usage for a resident with respiratory issues, as the resident was observed not wearing the nasal cannula despite the order. Additionally, the facility did not ensure proper storage of oxygen masks and routine changing of oxygen tubing for infection control, as observed with another resident receiving nebulizer treatments. Staff interviews confirmed expectations for monitoring and storage were not met.
The facility did not ensure that NAs employed for over four months were certified, affecting five NAs. Despite being enrolled in a 16-hour online course, delays in testing and lack of oversight by the ADON contributed to the issue. Some NAs faced challenges in finding testing sites, prolonging the certification process.
A resident was prescribed Haldol without proper documentation to support its clinical need, leading to an increase in falls and continued behavioral issues. The facility failed to monitor for adverse effects or medication effectiveness, and did not document the resident's ongoing obsession with dying. Staff interviews revealed a lack of behavior charting and follow-up with the psychiatrist, highlighting deficiencies in medication management and resident care.
The facility failed to maintain RN coverage for eight consecutive hours per day, seven days a week, and did not have a full-time Director of Nursing (DON). The ADON, an LPN, assumed DON responsibilities and consulted with a DON from a sister facility. Despite efforts to recruit, the facility did not meet regulatory requirements for RN coverage, as confirmed by staff interviews and record reviews.
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.
Failure to Investigate Falls and Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to thoroughly investigate and evaluate each resident fall to determine the cause and did not implement new or modify existing interventions to prevent future falls or reduce the risk of injury. Additionally, the care plans for residents with a history of falls were not updated to reflect current fall interventions, and there was no effective system in place to communicate these interventions to staff. These deficiencies were identified in three residents with a history of falls, all of whom experienced multiple incidents without adequate follow-up or documentation of interventions. One resident with severe cognitive impairment and a history of dementia experienced several falls, some resulting in injuries such as lacerations and hematomas. Despite physician orders for interventions like a soft helmet and floor mats, these were not consistently documented in the care plan or implemented by staff. Observations revealed that required safety equipment was sometimes missing or not used as ordered, and staff were unaware of current interventions due to outdated or missing communication tools. Interviews with CNAs indicated confusion about when and how to use fall prevention measures, and the Director of Nursing confirmed that interventions were not always added to care plans or communicated effectively. Another resident with moderately impaired cognition and a diagnosis of cancer experienced multiple falls, including incidents where the resident fell from bed or a wheelchair, sometimes sustaining injuries. Documentation of these events was inconsistent, and interventions such as fall mats were not always present or documented in the care plan. A third resident with severe cognitive impairment and mobility limitations also experienced a fall, but there was insufficient documentation regarding the circumstances of the fall or the use of safety equipment like side rails. The facility lacked a consistent process for post-fall investigation and failed to ensure that all staff were informed of and implemented appropriate fall prevention interventions.
Failure to Provide Timely Dental Care Following Tooth Injury
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who experienced a chipped front tooth while at the facility. The resident, who was cognitively intact but dependent for transfers, dressing, and wheelchair locomotion, had multiple diagnoses including diabetes, hemiplegia, stroke, seizures, and malnutrition. The resident's oral/dental status was left blank on the Minimum Data Set, and there was no documentation regarding oral care in the care plan. After the tooth broke, the resident reported pain and difficulty eating, and repeatedly communicated these issues to staff, but did not receive timely dental care. The resident's dental needs were not addressed promptly. Although a dental appointment was scheduled, the resident was unable to be seen due to an inability to transfer to the dental chair. No alternative arrangements were made, and the resident continued to experience pain and embarrassment about the appearance of the tooth. Staff interviews revealed a lack of follow-up and communication regarding the resident's ongoing dental issues, with the social worker and nursing staff each assuming the other was responsible for arranging care. The resident and family made several requests for dental care, but these were not acted upon in a timely manner. The resident eventually developed a dental abscess, for which a physician prescribed antibiotics. However, there was no evidence of further dental intervention or resolution of the underlying dental problem. Staff were unaware of the resident's ongoing pain and the need for dental care, and there was no documentation of follow-up or reassessment after the initial failed dental appointment. The lack of coordination and follow-through resulted in the resident waiting over a year without appropriate dental care.
Failure to Protect Resident from Abuse and Delay in Investigation
Penalty
Summary
The facility failed to protect a resident from abuse when an allegation of physical abuse was made against a CNA. A registered nurse heard yelling, banging, and a loud slap coming from a resident's room, followed by the CNA holding the resident against the wall. The nurse reported the incident to the DON, who instructed the nurse not to send the CNA home due to staffing shortages. The CNA continued to provide care to other residents for over five hours after the allegation was reported, and no immediate investigation was initiated. The resident involved had Alzheimer's disease, severe cognitive impairment, and required substantial assistance with activities of daily living. The care plan indicated the resident could be resistive to care and potentially physically aggressive, but interventions were in place to de-escalate situations and avoid physical confrontation. Despite these interventions, staff interviews revealed that some staff believed it was necessary to use a loud voice or physical restraint, and the CNA admitted to raising their voice and physically holding the resident against the wall during care. Interviews with facility staff, including the DON, ADON, and other personnel, revealed a lack of timely notification, investigation, and adherence to abuse prevention policies. The DON did not immediately suspend the accused CNA or begin an investigation, and several staff members were unclear about their responsibilities in reporting and responding to abuse allegations. Additionally, some non-nursing staff had not received recent training on abuse policies and were uncertain about their role in reporting suspected abuse.
Failure to Ensure Safe Mechanical Lift Transfers and Accident Prevention
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, specifically during mechanical lift (Hoyer) transfers. In one incident, a Certified Nurse Aide (CNA) performed a Hoyer lift transfer for a resident without the required assistance of a second staff member. During this transfer, the lift struck the resident in the face, resulting in a laceration, bruising, and swelling. The CNA did not report the incident to the nurse on the evening shift, and neurological assessments were not performed for 72 hours following the injury, contrary to facility policy. The resident involved had a history of repeated falls, muscle weakness, dementia, and was dependent for transfers, with physician orders for fall mats and a low bed, but these interventions were not consistently implemented or documented in the care plan. In a separate event, a Certified Medication Technician (CMT) also performed a Hoyer lift transfer for the same resident without a second person and failed to ensure that physician-ordered fall mats were in place at the bedside. After the transfer, the resident fell from bed, sustained a head injury, and required stitches. The CMT admitted to not following the two-person transfer protocol and not placing the fall mats before leaving the room. The care plan did not include the use of fall mats and a low bed as interventions, despite physician orders and the resident's high fall risk status. Additionally, direct observation revealed that staff did not consistently use proper Hoyer lift techniques during transfers. Two nurse aides, both new to the facility, attempted a two-person Hoyer transfer without adequate training, resulting in the lift tilting multiple times and the resident being bumped and dropped rapidly onto the bed. The aides reported not receiving hands-on training at the facility and relied on previous experience or observation. These failures in supervision, adherence to policy, and staff training led to multiple incidents where the resident was exposed to significant accident hazards.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency within the required timeframe. According to the facility's policy, all alleged violations involving abuse must be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. On the day of the incident, a registered nurse (RN) heard yelling, threatening language, and a loud slap coming from a resident's room. Upon entering, the RN observed a certified nurse aide (CNA) physically holding the resident against the wall. The resident, who had severe cognitive impairment, was unable to provide clear information about the incident. The RN reported the observation to the Director of Nurses (DON) shortly after the event. Despite being informed of the situation, the DON did not report the allegation to the Department of Health and Senior Services (DHSS) within the required two-hour window, stating that more details were needed before making a report and expressing a lack of awareness of the reporting requirement. Other facility leaders, including the Assistant Director of Nurses (ADON) and Assistant Administrator, were not made aware of the allegation until several hours later. The facility's failure to promptly report the abuse allegation as required by policy and regulation constituted the deficiency.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for three consecutive fiscal quarters preceding the annual survey. The specific quarters in question were fiscal year quarter 1, 2024 (October 1 to December 31), fiscal year quarter 2, 2024 (January 1 to March 31), and fiscal year quarter 3, 2024 (April 1 through June 30). During an interview, the Assistant Administrator acknowledged that it was his responsibility to submit the Payroll Based Journal (PBJ) report to CMS and admitted that he was aware of the requirement but had not fulfilled it. The facility had a census of 47 at the time of the survey.
Failure to Maintain Resident Dignity Due to Staff Cell Phone Use
Penalty
Summary
The facility failed to uphold the dignity of its residents by allowing staff to use cell phones during care, which was against the facility's policy. Multiple observations were made where staff members, particularly Nurse Aide (NA) E, were seen using their phones while attending to residents. For instance, NA E was observed texting while feeding a resident with severe cognitive impairment, not paying attention to the resident's needs. Another resident with moderate cognitive impairment felt uncomfortable when NA E entered their room and used their phone without interacting with them. Additionally, a cognitively intact resident reported feeling uneasy when NA E was on a phone call during their care. The facility also failed to ensure that staff were appropriately seated while feeding residents, which is essential for maintaining dignity and respect. Observations showed that NA C stood over residents with severe cognitive impairments while feeding them, rather than sitting at their level. This practice was noted during multiple instances, indicating a lack of adherence to the facility's dignity policy. Furthermore, the facility did not ensure that residents received necessary assistance during meals. A resident with severe cognitive impairment and dystonia was observed struggling to eat with their hands after dropping their spoon, without receiving help from staff to replace the utensil. This lack of assistance persisted throughout the meal, highlighting a failure to provide dignified care. Interviews with staff and residents confirmed that cell phone usage during care was a common issue, despite the facility's policy prohibiting it.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans with resident-specific interventions for five residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. For one resident, the care plan did not include specific interventions for significant weight loss, use of an indwelling catheter, and active wounds, despite the resident having multiple medical conditions such as stroke, diabetes, and pressure ulcers. Observations and interviews revealed that the resident had a catheter, was on a pureed diet, and had unplanned weight loss, yet these were not reflected in the care plan. Another resident with severe cognitive impairment and a history of falls, including a hip fracture, had a care plan that was not updated to reflect these incidents or the resident's current use of a wheelchair. The resident also exhibited ongoing thoughts about death and dying, which were not addressed in the care plan. Staff interviews indicated that the resident's condition had declined, and the resident frequently expressed anxiety and confusion about dying, yet the care plan lacked specific interventions to manage these behaviors. A third resident, who was underweight and had significant weight loss, had a care plan that failed to address the resident's dietary needs and preferences, such as eating with hands and refusing assistance. Despite receiving dietary supplements and having a divided plate to aid in eating, these interventions were not documented in the care plan. Observations showed the resident eating with hands and dropping food, while staff interviews confirmed the resident's refusal of assistance and significant weight loss.
Inadequate Supervision and Transfer Protocols
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for several residents. Two residents were observed being propelled in wheelchairs without leg rests, causing their feet to drag on the floor. This occurred despite the residents' difficulty in keeping their legs elevated, leading to discomfort and potential injury. Staff members were aware of the issue but did not consistently use leg pedals or other appropriate measures to prevent the residents' feet from dragging. Additionally, the facility staff did not use gait belts during assisted transfers for three residents, which is a standard safety protocol. Observations showed staff lifting residents by their arms or clothing, which is inappropriate and poses a risk of injury. Interviews with staff and the Assistant Director of Nursing confirmed that gait belts should be used during transfers, yet this practice was not consistently followed. Furthermore, a resident with a history of falls was not appropriately repositioned in their wheelchair, despite being observed leaning and slouched in the chair on multiple occasions. Staff interviews revealed an expectation for frequent rounds and repositioning to ensure the resident's safety, but these measures were not adequately implemented. The lack of a written policy regarding transfer protocols further contributed to these deficiencies.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. The facility's staffing policy, revised in April 2007, mandates adequate staffing to meet the care and service needs of the resident population, including the availability of licensed RN and nursing staff to provide and monitor resident care services. However, a review of staffing sheets from October 1 to October 21, 2024, revealed multiple days without RN coverage, specifically on October 1, 2, 3, 4, 6, 8, 10, 11, 13, 14, and 19. During interviews, the Assistant Director of Nursing acknowledged the requirement for RN coverage and cited difficulties in securing RNs to work, despite posting requests on the agency website. The Assistant Administrator also expressed an expectation for RN staffing to be covered as required.
Deficiency in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation on two out of three medication carts reviewed. This deficiency was identified during a review of the facility's Controlled Substances policy, which mandates compliance with laws and regulations related to the handling, storage, disposal, and documentation of controlled substances. The policy requires nursing staff to count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty participating in the count. However, the review of Narcotic Count Sheets from 10/1 through 10/19/24 revealed significant non-compliance, with numerous shifts lacking the required dual nurse initials on the shift change count. Specifically, on the 400 and 500 medication carts, 22 out of 57 shifts had no nurse initial, and 28 shifts had only one nurse initial. Similarly, on the 100, 300, and 600 medication carts, 23 out of 57 shifts had no nurse initial, and 28 shifts had only one nurse initial. Interviews with staff, including a Certified Medicine Technician and a Licensed Practical Nurse, confirmed that the expected practice was for two staff members to sign the narcotic book and complete the count every shift. The Assistant Director of Nursing also stated that she expected narcotics to be counted and documented by two different staff members every shift. This failure in documentation and procedure had the potential to affect all residents with controlled substance orders, with the facility census being 47.
Improper Storage of Medications and Lack of Temperature Monitoring
Penalty
Summary
The facility failed to ensure that drugs and biologicals stored in the medication room refrigerator were maintained at the proper temperature, as there was no system or temperature log in place. During an observation, it was noted that the refrigerator contained a thermometer hanging on the inside of the door, but there was no record of temperature monitoring. Certified Medication Technician (CMT) F and Licensed Practical Nurse (LPN) A both confirmed the absence of a temperature log and were unaware of who was responsible for checking the refrigerator's temperature. Additionally, the facility did not adhere to the policy of storing medications separately from food items. The medication room refrigerator contained not only medications such as insulin vials, tuberculin testing serum, and Ativan but also several cartons of nutritional supplements like Nepro, Boost, and Med Pass, as well as a clear plastic bowl of applesauce. The Assistant Administrator and the Assistant Director of Nursing (ADON) admitted that they were not aware of the requirement to store medications separately from food items and confirmed the lack of a system to monitor the refrigerator's temperature.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during meal service, affecting 15 residents. Observations during breakfast and lunch revealed that staff members, including a Licensed Practical Nurse (LPN) and Nurse Aides (NAs), did not perform hand hygiene before or after assisting residents with meals, handling food, or touching residents and their belongings. This was contrary to the facility's hand hygiene policy, which mandates handwashing or the use of an alcohol-based hand rub before and after direct contact with residents and handling food. During breakfast, a Nurse Aide was observed assisting multiple residents with their meals and personal items without performing hand hygiene. The aide repositioned residents, handled their silverware, and assisted with feeding without washing hands or using hand sanitizer. Similar observations were made during lunch, where another Certified Nursing Assistant (CNA) and a Nurse Aide were seen assisting residents with their meals and personal items without adhering to hand hygiene protocols. Interviews with staff members, including a CNA, a Certified Medication Technician (CMT), and a Licensed Practical Nurse (LPN), confirmed that the expectation was for staff to perform hand hygiene before entering the dining room, after passing each plate, and after touching any items. The Assistant Director of Nursing (ADON) and the Administrator also stated that they expected all staff to follow the hand hygiene policy. Despite these expectations, the observations indicated a failure to comply with the facility's hand hygiene procedures, leading to the deficiency.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, particularly in the use of Enhanced Barrier Precautions (EBP) for residents with urinary catheters and wounds requiring treatment. Specifically, staff did not adhere to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for EBP, which require gown and glove use during high-contact resident care activities. Observations revealed that staff did not wear gowns while providing care to residents with urinary catheters and wounds, and there was no EBP signage outside the residents' rooms. Interviews with staff, including CNAs, LPNs, and the Assistant Director of Nursing (ADON), indicated a lack of awareness and training regarding EBP. In addition to the failure to implement EBP, the facility did not follow acceptable infection control standards during wound care procedures. For instance, an LPN was observed using ungloved hands to handle unpackaged dressings and scissors that were not cleaned before use. The LPN also failed to label or date the wound dressing after application. These actions were contrary to the facility's wound care policy, which requires hand hygiene, the use of gloves, and the cleaning of equipment before use. Furthermore, the facility did not conduct tuberculosis (TB) testing for several residents as required by its TB policy. The policy mandates TB screening for all residents upon admission, with a two-step tuberculin skin test (TST) or a blood assay for Mycobacterium tuberculosis (BAMT). However, records showed that five residents had no documentation of TB screening or testing. The ADON acknowledged the oversight and stated that TB screening and testing should be completed for all residents upon admission and annually thereafter.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and administer the pneumococcal vaccine to four out of five sampled residents, despite having a policy in place that mandates offering the vaccine to eligible residents. The policy, revised in August 2016, requires that residents be assessed for vaccine eligibility upon or prior to admission and be offered the vaccine within thirty days unless contraindicated or previously vaccinated. However, the medical records for Residents #12, #11, #38, and #22 showed no documentation of screening or vaccination, despite their various medical conditions, including stroke, diabetes, heart failure, sepsis, and respiratory failure. The Assistant Director of Nursing (ADON), responsible for screening and checking vaccine status, confirmed that residents should be offered the vaccine if eligible and that refusals should be documented. Additionally, education about the vaccine's benefits and potential side effects should be provided to residents or their representatives, with documentation in the medical record. The lack of documentation and action regarding the pneumococcal vaccine for these residents indicates a failure to adhere to the facility's vaccination policy.
Failure to Offer COVID-19 Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to four out of five residents sampled for immunizations, despite having a policy in place that mandates offering the vaccine to all eligible residents. The policy, revised in May 2023, requires that each resident be offered the COVID-19 vaccine unless medically contraindicated or already fully vaccinated. The Assistant Director of Nursing (ADON) is responsible for overseeing the education, documentation, and reporting of vaccination status. However, the medical records of Residents #11, #38, #22, and #14 showed no documentation of screening or vaccination, indicating a lapse in following the facility's policy. Resident #11, admitted with diagnoses including sepsis and acute respiratory failure, had no documentation of being screened or offered the vaccine. Similarly, Resident #38, with conditions such as adult failure to thrive and diabetes, and Resident #22, with sepsis and long-term antibiotic use, also lacked documentation of screening or vaccination. Resident #14, who had received initial doses of the COVID-19 vaccine in early 2021, had no further documentation of additional vaccinations or screenings. The ADON confirmed during an interview that it was expected for residents to be offered the vaccine and for refusals to be documented, highlighting a deficiency in the facility's adherence to its vaccination policy.
Deficiency in CNA Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of ongoing education annually. This deficiency was identified for five out of five sampled CNAs, with a facility census of 47. The facility was unable to provide a policy related to the 12-hour training requirement for CNAs. Employee files for CNAs and Certified Medication Technicians (CMTs) showed no records of in-service training. Interviews revealed that the facility provides in-services, but there is no formal tracking or documentation system in place. The Assistant Director of Nursing (ADON) acknowledged that it is her responsibility to maintain a system for tracking in-service training but admitted to not doing so, and could not provide any documentation of completed in-services.
Failure to Notify Physician and Resident of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the physician of abnormal lab results for a resident diagnosed with a urinary tract infection (UTI). The resident's urinalysis and culture results, which indicated the presence of Citrobacter farmeri bacteria, were collected and reported to the facility but were not communicated to the physician until two days later. This delay in communication resulted in a delay in receiving new orders for antibiotic treatment. Additionally, the facility did not inform the resident or the resident's representative about the abnormal lab results and the new medication orders. The resident reported experiencing intense burning and was unaware of the UTI diagnosis until after starting the antibiotic treatment. The resident's power of attorney (POA) was also not informed about the UTI diagnosis or the new medication orders. Interviews with facility staff, including an LPN, the Assistant Director of Nurses (ADON), and the Assistant Administrator, revealed that there were expectations for timely lab collection and communication of results. However, the facility's process for handling lab results, especially those received on weekends, was inadequate, leading to a lack of timely notification to the physician and the resident. Documentation of communication with the physician, resident, and responsible party was also lacking in the resident's electronic medical record (EMR).
Failure to Provide Written Notices of Transfer/Discharge
Penalty
Summary
The facility failed to provide emergency written notices of transfer or discharge to two residents who were transferred to the hospital for acute medical reasons. The facility's policy, revised in December 2016, requires that residents and/or their representatives receive a 30-day written notice of an impending transfer or discharge, or as soon as practicable in cases of urgent medical needs. However, for Resident #31, there was no documentation of written notice for transfers to the hospital on two occasions, and for Resident #19, there was no documentation of written notice for a transfer to the hospital. Interviews with facility staff, including an LPN and the Assistant Director of Nurses (ADON), revealed that while paperwork such as the resident's face sheet and medication list is sent with the resident to the hospital, the practice of sending a notice of transfer/discharge had lapsed. The ADON confirmed the absence of documentation for the required notices for the residents in question. The Assistant Administrator also stated the expectation that residents and/or their representatives should receive a notice of transfer/discharge when a resident is transferred to the hospital.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide written information on its bed hold policy to residents and/or their representatives at the time of transfer to a hospital for two residents. The facility's policy, revised in March 2017, mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to any transfers or therapeutic leaves. However, for two residents who were transferred to the hospital for acute medical reasons, there was no documentation indicating that they or their representatives received the required written notice. Specifically, Resident #31 was transferred to the hospital on two occasions, and Resident #19 was transferred once, with no evidence of the bed hold policy being communicated in writing during these transfers. Interviews with facility staff revealed a lapse in the process of providing bed hold notices. An LPN mentioned that while paperwork such as the resident's face sheet and medication list is sent with the resident to the hospital, the practice of including a bed hold notice had ceased some time ago. The Assistant Director of Nurses confirmed the absence of documentation for the bed hold notices for the two residents in question and expressed an expectation that such notices should be provided. Similarly, the Assistant Administrator stated that residents and/or their representatives should receive a bed hold notice upon hospital transfer, indicating a discrepancy between expected procedures and actual practice.
Inaccurate Resident Assessment Leads to Oversight of Health Issues
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, resulting in the oversight of significant health issues. The resident experienced an unplanned significant weight loss of 18.48% over six months, dropping from 147.2 pounds to 120.0 pounds. Despite this, the resident's Minimum Data Set (MDS) inaccurately indicated that the weight loss was part of a physician-prescribed regimen. Additionally, the resident had a Stage II pressure ulcer on the left buttock and a Stage IV pressure ulcer on the sacrum, which were not documented in the MDS. Instead, the focus was incorrectly placed on the resident's bullous pemphigoid wounds, leading to the omission of these critical skin conditions. The Assistant Director of Nurses (ADON), responsible for completing the MDS assessments, admitted to misinterpreting the weight loss question and failing to accurately document the resident's pressure ulcers. The ADON's focus on the bullous pemphigoid areas contributed to the oversight of the pressure ulcers. The Assistant Administrator also expressed an expectation for accurate resident assessments, highlighting a lapse in the facility's assessment process for this resident.
Failure to Maintain Comprehensive Care Plans
Penalty
Summary
The facility staff failed to review and revise the care plans for four residents, despite changes in their care needs. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of the comprehensive assessment and revised as the resident's condition changes. However, the review of the electronic medical records (EMR) for Residents #38, #46, #22, and #32 revealed that they did not have comprehensive care plans, which is a violation of the facility's policy. Resident #38, diagnosed with cerebral aneurysm, diabetes, high blood pressure, depression, and seizures, was admitted on a specified date, but the EMR review showed no comprehensive care plan. Similarly, Resident #46, with diagnoses including depression, dementia, and anxiety, also lacked a comprehensive care plan in the EMR. Resident #22, with moderately impaired cognition and diagnoses of type two diabetes mellitus and depression, and Resident #32, diagnosed with depression, dementia, weakness, high blood pressure, and anemia, were also found without comprehensive care plans in their EMRs. Interviews with facility staff, including LPNs and CNAs, revealed that while they have access to the EMR and are expected to view care plans, they often rely on verbal instructions from charge nurses due to the absence of care plans in the EMR. The Assistant Director of Nursing (ADON) acknowledged that the care plans were not in the EMR due to an error during their creation, and confirmed that care plans should be completed within the appropriate time frame as per the facility's policy.
Deficiency in CPR Certification Training
Penalty
Summary
The facility failed to ensure that all staff certified in cardiopulmonary resuscitation (CPR) received their certification through a provider whose training includes hands-on practice and in-person skills assessment. Out of 10 CPR-certified staff, three were found to have obtained their certification through an online provider, which does not meet the regulatory requirements for CPR training. This deficiency was identified during a review of the facility's CPR certification records and interviews with staff, including the Assistant Director of Nurses (ADON) and a Registered Nurse (RN). The facility's Advance Directives policy lacked guidance on ensuring CPR certification included hands-on practice and in-person skills assessment. The review of nurse staffing sheets revealed that on multiple occasions, the only CPR-certified staff scheduled were those with online certifications. Interviews with the ADON and Assistant Administrator confirmed that they expected CPR-certified staff to have received training that includes hands-on practice, but they were unaware of the specific regulatory requirements. The facility had 22 residents with full code status, indicating the importance of having properly certified staff available.
Inadequate Wheelchair Assessment and Undated Dressing
Penalty
Summary
The facility failed to provide services consistent with acceptable standards of practice for a resident when staff did not accurately assess the appropriate wheelchair size, leading to skin irritation and indentations on the resident's legs. The resident, who had a diagnosis of dementia, depression, high blood pressure, high cholesterol, peripheral vascular disease, and was overweight, was observed sitting in a wheelchair that was not their property. The resident complained of pain in their bottom, back, and legs, and was unable to reposition themselves. Staff failed to reposition the resident for six hours, despite the resident's repeated requests to be moved to bed. Observations revealed indentations and reddened areas on the back of the resident's calves and thighs, attributed to the wheelchair's foot pedal brackets applying pressure. Additionally, the facility failed to date a dressing for another resident, who had a diagnosis of diabetes, high blood pressure, high cholesterol, kidney disease, amputation, and dementia. The resident was observed with a dressing on their right lower leg that was not dated on multiple occasions. Staff were unable to identify when the dressing was applied, and it was later noted that the abrasion occurred on a specific date. The Assistant Director of Nursing expected the nursing staff to date the dressing when the treatment was performed. These deficiencies highlight the facility's failure to adhere to acceptable standards of practice in assessing and addressing residents' needs, particularly in ensuring appropriate equipment and documenting care procedures. The lack of proper assessment and documentation led to discomfort and potential harm to the residents involved.
Inadequate Foot Care for Residents
Penalty
Summary
The facility failed to provide adequate foot care for two residents, resulting in long nails and dry feet. Resident #44, who is cognitively intact and has diabetes, reported having dry, flaky skin and excessively long toenails, which caused discomfort and difficulty wearing shoes. Despite being at the facility for eight months, Resident #44 had not yet seen a podiatrist, and the issue was not documented in the resident's most recent skin evaluation. Resident #21, who has severe cognitive impairment and multiple diagnoses including dementia and COPD, also exhibited long, jagged toenails and dry, flaky skin. The resident's care plan included interventions for nail care, but the most recent shower sheets and skin evaluation did not document any concerns. Although the resident refused podiatry care at the last appointment, family members expressed concern about the condition of the resident's nails. Interviews with facility staff, including CNAs and LPNs, revealed that both groups are responsible for foot care, with nurses specifically tasked with trimming nails for diabetic residents. Documentation of foot care issues should occur on shower sheets or skin assessments, but this was not consistently done. The Assistant Director of Nursing acknowledged the oversight in ensuring residents' foot care needs were met and noted that Resident #44 was on the list to see the podiatrist but was not seen during the last visit.
Failure to Follow Oxygen Therapy Orders and Infection Control Protocols
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident with an order for continuous oxygen usage. Resident #44, who was cognitively intact and diagnosed with anxiety, asthma, and acute respiratory failure, had a physician's order for continuous oxygen at 2 liters via nasal cannula. However, observations over several days showed the resident in bed with the oxygen concentrator on but not wearing the nasal cannula. Interviews with staff, including a CNA, LPN, and the ADON, revealed that the resident frequently removed the nasal cannula, and there was an expectation for frequent monitoring to ensure the resident wore it. The care plan did not address the resident's behavior of removing the nasal cannula. Additionally, the facility failed to ensure proper storage of oxygen masks and routine changing of oxygen tubing for infection control purposes. Resident #14, who had severe cognitive impairment and diagnoses including wheezing and dementia, had an order for nebulizer treatments. Observations showed the nebulizer mask uncovered on a side table, contrary to staff expectations that it should be stored in a plastic bag when not in use. Interviews with staff confirmed the expectation for proper storage of the nebulizer mask, but the care plan did not include the resident's nebulizer use.
Failure to Certify Nursing Assistants Within Required Timeframe
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) employed for more than four months were certified, affecting five NAs in total. The facility's assessment, reviewed in July 2023, indicated that staff training and education, including certification and licensure requirements, were necessary to provide the required level of care. However, a review of the hire dates for the NAs showed that none of them were certified within the required four-month period. Interviews with the NAs revealed that they were either waiting to test out or waiting for approval to retake the test, indicating a delay in the certification process. The Assistant Director of Nursing (ADON) stated that all NAs were enrolled in a 16-hour online course and were responsible for completing the program and the test. Some NAs had failed their tests and needed to retake the course. The ADON mentioned that she could not track the progress of the NAs' online training and was unaware of any requirement to sign off on their completion. Additionally, some NAs faced challenges in finding a testing site, leading to a prolonged period between finishing the course and taking the test.
Inadequate Documentation and Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the prescription of Haldol without appropriate documentation to support its clinical need. The resident, who had a history of major depressive disorder and anxiety disorder, was prescribed Haldol despite the absence of documented behaviors or symptoms that would justify its use. The facility's policy on antipsychotic medication use requires thorough documentation and evaluation of a resident's behavior and symptoms before such medications are prescribed, which was not adhered to in this case. The resident experienced an increase in falls following the adjustment of psychotropic medications, including the addition of Haldol, yet there was no documentation of monitoring for adverse consequences or medication effectiveness. The resident's medical record showed multiple falls and hospitalizations for a fractured femur, but there was no evidence of follow-up visits with the psychiatrist after the medication changes. The facility's care plan for the resident did not include documentation related to the resident's expressed thoughts or anxiety about dying, which was a significant behavior noted by staff. Observations and interviews with staff revealed that the resident was frequently confused and obsessed with thoughts of dying, a behavior that had been ongoing since the resident's admission. Despite the prescription of Haldol, the resident continued to exhibit these behaviors, indicating a lack of effectiveness of the medication. The facility did not utilize behavior charting, which could have provided valuable insights into the resident's condition and the impact of the medication. The lack of documentation and monitoring highlights a deficiency in the facility's management of psychotropic medications and resident care.
Failure to Maintain RN Coverage and Designate a Full-Time DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis. This deficiency had the potential to affect all residents, with a census of 50. The facility's list of Department Heads showed no DON employed, and daily assignment sheets indicated no RN coverage on several days. Interviews with staff, including a Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and the Assistant Director of Nursing (ADON), confirmed the absence of a DON for several months and inconsistent RN coverage. The ADON, who is an LPN, assumed the responsibilities of the DON and consulted with a DON from a sister facility as needed. The ADON acknowledged the requirement for RN coverage and the facility's ongoing search for a DON and full-time RNs. The Assistant Administrator also confirmed the lack of a DON and stated that the facility used staffing agencies to meet RN needs. Despite these efforts, the facility did not meet the regulatory requirement for RN coverage, as confirmed by multiple staff interviews and record reviews.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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