Bernard Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4335 West Pine Blvd, Saint Louis, Missouri 63108
- CMS Provider Number
- 265500
- Inspections on file
- 21
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Bernard Care Center during CMS and state inspections, most recent first.
The facility discontinued services with a long-standing attending physician and reassigned all affected residents to another physician despite many residents and their representatives clearly expressing a desire to remain with the original provider. Social Services documented that residents and guardians were informed of their right to choose a physician and were told they could continue with the original physician through outside appointments with facility-assisted transportation, yet medical records were changed to list a different PCP, and no transportation was actually arranged. Several cognitively intact or partially impaired residents, and guardians for residents with severe cognitive impairment and complex conditions such as HTN, DM, stroke, CP, schizophrenia, and dementia, reported wanting to keep the original physician but felt compelled to accept the change due to statements that the physician would no longer be allowed in the facility and lack of practical means to access outside care. The DON later confirmed that residents were switched to a new PCP because of a corporate deadline and that no transportation had been set up for those wishing to remain with the original physician.
Multiple deficiencies were observed, including excessive noise from loud announcements and a slamming smoke room door, unsanitary conditions such as soiled briefs left on a bathroom floor and a clogged, dirty toilet that remained unaddressed for days, and widespread maintenance issues like dirt buildup, chipped paint, broken fixtures, and exposed wiring throughout the facility. Staff interviews confirmed that short staffing and lack of a set deep cleaning schedule contributed to the failure to maintain a clean and comfortable environment for residents.
Several residents with cognitive impairment and chronic conditions did not receive proper foot care, including podiatry services, as required by facility policy and physician orders. Observations showed long, thick toenails and extremely dry feet, while interviews revealed that residents had not been seen by a podiatrist and desired better foot care. Staff interviews confirmed inconsistent assessment, documentation, and referral practices, resulting in unmet foot care needs.
The facility did not maintain proper food temperatures or palatability during meal service, as observed with cold and unappetizing food items and confirmed by two residents with multiple medical and mental health diagnoses. Staff interviews revealed that elevator malfunctions led to delays in food delivery, resulting in meals being served below required temperatures and in an unpalatable state.
A resident with bilateral leg amputations was unable to access their electric wheelchair while it was being repaired in the basement due to a nonfunctional elevator. The resident, who requires total assistance and has no trunk control, was left in bed without a suitable alternative mobility device, leading to frustration and distress.
The facility did not maintain a functioning exhaust system in the indoor smoke room, resulting in cigarette smoke and odor spreading into hallways and dining areas. Multiple staff and residents reported strong smoke odors and visible smoke outside the smoke room, and ventilation fans were found to be either turned off or not working due to power issues.
Surveyors found that multiple hallways and areas lacked required handrails or had handrails that were loose, broken, or missing. Observations included missing handrails near dining rooms, nurses' stations, and restrooms, as well as handrails pulled away from the wall. Interviews with the Maintenance Director and Administrator confirmed awareness of the issue and ongoing replacement efforts, but also revealed gaps in knowledge regarding handrail placement requirements.
A resident with a suprapubic catheter experienced pain after an LPN flushed the catheter without a physician's order, contrary to facility policy. The resident's medical records lacked documentation of the procedure, and the incident led to an ER visit where trauma from the manipulation was suspected. Staff interviews confirmed the deviation from protocol.
The facility failed to ensure that personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for the residents. Withdrawals for personal spending were not properly authorized, and items purchased with these funds were not found in the residents' possession. The facility's Financial Coordinator and Life Enrichment Director admitted to mixing up gift cards and receipts, leading to improper accounting of resident funds.
The facility failed to follow general accounting principles by not addressing outstanding checks during monthly resident trust fund reconciliations. Multiple checks, some dating back to 2015, remained outstanding, indicating a lapse in following procedures. The Financial Coordinator was not trained to investigate these checks and lacked the authority to void them, leading to the deficiency.
The facility failed to provide a homelike environment by serving meals on Styrofoam plates with plastic utensils, which residents found difficult to use. Additionally, a resident was given a visibly dirty wheelchair, and multiple resident rooms were observed to be unclean with sticky floors, dirty privacy curtains, and dusty air conditioning units. Staff interviews confirmed these deficiencies.
The facility failed to update care plans to reflect the needs of three residents who smoke and one resident who frequently refuses medications. Despite observations and staff interviews confirming these behaviors, the care plans did not include this critical information.
The facility failed to appropriately assess and investigate a series of falls resulting in head injuries for a resident, did not use functional equipment during mechanical lift transfers for two residents, and did not apply gait belts properly during transfers or assisted ambulation for three residents. Additionally, the facility did not ensure residents were routinely and accurately assessed for smoking safety.
The facility failed to ensure that residents using side rails were appropriately assessed for safety, as required by their policy. Four residents were observed with side rails without proper assessments or documentation in their care plans. Staff interviews revealed confusion about the responsibility and frequency of these assessments, indicating a systemic issue in policy adherence.
The facility failed to maintain accurate records for controlled substances, as manual end-of-shift narcotic counts were not consistently completed for two out of three medication carts. Staff interviews confirmed the requirement for daily counts, but records showed multiple instances of non-compliance.
The facility failed to ensure that food delivered to residents was palatable and at the required temperatures. Observations and interviews revealed that food served to residents in their rooms on the 300 and 400 hallways was often unappetizing, bland, and not at the proper temperatures. For instance, a resident who is dependent on assistance with eating and has diagnoses including stroke and dysphagia, was served rubbery grits that could not be cut with a fork and pureed food that was unidentifiable and unpalatable. Another resident, who requires setup or clean-up assistance with eating and has similar diagnoses, reported that the food was
The facility failed to maintain cleanliness in the kitchen, walk-in refrigerator, and bulk storage areas, and did not ensure the ice machine had an air gap. Observations revealed water pooling, trash, food debris, and grime in various areas, with dietary staff and management confirming cleaning responsibilities were not met.
The facility failed to obtain and document necessary medical orders for a resident with severe cognitive impairment and multiple medical conditions, leading to lapses in care for PICC line, nephrostomy tube, and suprapubic catheter. Additionally, a required yearly EKG was not completed due to a backlog with the service provider.
The facility failed to ensure residents requiring assistance with ADLs received necessary services to maintain personal hygiene. One resident was left soiled for an extended period, resulting in a rash, while three other residents were observed with poor personal hygiene, including unshaven faces and long, jagged nails. Staff interviews revealed inconsistencies in care practices and documentation.
The facility failed to identify and obtain treatment orders for newly acquired skin issues in two residents, despite multiple observations and interactions with staff. The residents' care plans and progress notes did not document the skin conditions, and staff interviews confirmed that the required protocols for reporting and treating new skin issues were not followed.
The facility failed to ensure proper catheter care for two residents, leading to potential contamination and UTIs. Catheter bags were observed above the bladder and tubing was frequently in contact with the floor, contrary to the facility's policy.
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease. The resident did not have appropriate physician orders for pre and post-dialysis assessments, and there was a lack of documentation and communication with the dialysis center. Interviews with staff revealed inconsistencies in the documentation process, and the Director of Nursing confirmed that a new communication form was not consistently used.
The facility failed to follow infection control standards during peri-care for a resident and catheter treatment for another. A CNA did not change gloves or perform hand hygiene after providing peri-care, and an LPN did not clean scissors before using them to cut a dressing for a catheter site. Staff interviews confirmed these practices were against facility policies.
The facility failed to ensure all call lights were in working order, affecting a resident with multiple diagnoses including MS and hemiplegia. Despite the resident's care plan indicating the need for a functioning call light, the issue remained unresolved for about three weeks. Staff interviews revealed a lack of proper reporting and communication regarding the non-functioning call light.
Failure to Honor Residents’ Choice of Attending Physician After Termination of Physician Privileges
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their own attending physician after corporate leadership discontinued privileges for Physician A, who was caring for 35 residents. The facility’s Resident Rights policy states that residents have the right to choose a personal attending physician, be fully informed in advance about care and treatment and any changes that may affect their well-being, and participate in planning care and treatment. In early March, the DON and Administrator received an email from the corporate CNO stating that, effective at the end of the month, Physician A would no longer have privileges with the organization and instructing them to notify residents of the change and determine whether they wanted to stay with Physician A. Despite this, all of Physician A’s residents were changed to Physician B by the facility due to a corporate deadline, and no letter was issued to residents regarding the change. Multiple residents and their representatives expressed a clear preference to remain under the care of Physician A, but the facility did not coordinate continued access to that care. One cognitively intact resident with anxiety and depression was informed by Social Services that Physician A would no longer maintain privileges and that continued care would require outside appointments, with the facility assisting with transportation. The resident stated a desire to stay with Physician A, citing satisfaction and desire for continuity, yet the medical record listed Physician B as the PCP, and the resident later reported being told by the Activity Director that he had to change physicians because Physician A could no longer practice at the facility and the office was too far away. Another resident with moderate cognitive impairment, high blood pressure, anxiety disorder, and schizophrenia similarly expressed a preference to remain with Physician A, and Social Services documented that transportation assistance would be provided; however, the medical record also showed Physician B as the PCP, and the resident’s family member reported not being notified of the PCP change and wanting the resident to keep Physician A. Additional residents and guardians experienced the same pattern. A resident with no cognitive impairment, high blood pressure, and schizophrenia had a guardian who was notified that Physician A would lose privileges and who clearly stated a preference to keep Physician A, yet the resident’s record listed Physician B as PCP, and the guardian believed Physician A was still the PCP. Two other residents with severe cognitive impairment and diagnoses including stroke, cerebral palsy, high blood pressure, diabetes, and dementia were informed, along with their family, that Physician A would no longer have privileges and that continued care would require outside appointments with transportation assistance from the facility. Both residents expressed a preference to remain with Physician A, but their records listed Physician B as PCP. Their guardian reported being told that Physician A would no longer be allowed in the facility and, lacking a car to transport the residents, felt there was no real choice and agreed to the change. The DON later acknowledged that transportation had not been set up for residents who wanted to stay with Physician A and that, to her knowledge, Physician A did not have an office, while Physician A’s office manager stated that Physician A had not had an examination office for about 15 years and preferred to see residents onsite in the facility. These actions and omissions resulted in residents’ stated choices to remain with Physician A not being honored or facilitated.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Excessive noise levels were noted, including loud overhead announcements that interrupted resident conversations and a smoke room door that repeatedly slammed shut, disturbing residents in the vicinity. Despite previous attempts to fix the door, the issue persisted, and the noise was audible even in the administrator's office. No complaints were reported regarding the overhead speakers, but residents expressed discomfort with the noise disruptions. Sanitation and cleanliness issues were observed throughout the facility. In one instance, a resident's bathroom contained soiled briefs on the floor over multiple days, with staff indicating that residents were expected to request trash bags for disposal, and that housekeeping would not remove soiled briefs from bathrooms. Another resident's toilet was clogged and dirty with feces and toilet paper for at least two days, resulting in a strong odor permeating the room. The resident, who had diagnoses including major depressive disorder, schizoaffective disorder, and epilepsy, and was moderately cognitively impaired, reported being unable to use the toilet during this time. Widespread maintenance and cleanliness deficiencies were documented in various facility areas, including hallways, dining rooms, bathrooms, and common spaces. Observations included dirt buildup on floors and cove bases, chipped and missing paint, broken fixtures, exposed wiring, cracked tiles, and dirty or damaged windows. Staff interviews revealed that short staffing, particularly in housekeeping and floor technician roles, contributed to lapses in deep cleaning and maintenance. Housekeeping and laundry staff were often required to cover for each other, and there was no set schedule for deep cleaning. Staff acknowledged that the environment was not being maintained to expected standards, with visible dirt, dust, and damage throughout the facility.
Failure to Provide Proper Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care to five residents, as evidenced by observations, interviews, and record reviews. Residents with moderate cognitive impairment and various diagnoses, including diabetes, peripheral vascular disease, and schizophrenia, were found to have unaddressed foot care needs. Despite facility policies requiring assessment, routine care, and referral to a podiatrist for residents with complicating conditions, there was no documentation of podiatry visits or consults for these residents, even when physician orders allowed for podiatrist visits. Direct observations revealed that several residents had excessively long, thick, jagged, and curled toenails, as well as extremely dry feet with large flakes of skin. Some residents wore socks with holes or soiled socks, and in one case, a resident reported discomfort due to a long toenail rubbing against footwear. Interviews with residents confirmed that they had not received podiatry services or adequate foot care, and some expressed a desire for their feet to be moisturized or toenails to be trimmed by a professional. Staff interviews indicated that while there were expectations for nurses and aides to assess, moisturize, and refer residents for podiatry care, these actions were inconsistently carried out. Staff acknowledged that refusals of care should be documented, but there was no evidence of such documentation or follow-up in the medical records. The lack of documented podiatry visits, inadequate routine foot care, and failure to address residents' expressed needs and physician orders led to the deficiency.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature during tray service, as required by their dietary food preparation policy. Observations revealed that hot foods, such as sausage patties and scrambled eggs, were served below the acceptable temperature threshold, with the sausage patty measuring 93°F and the eggs at 115.9°F, both of which felt cold. Additionally, lunch service included chicken strips that tasted rubbery, limp and damp bread, and mashed potatoes that were dry, bland, and powdery without gravy. These issues were directly observed during meal service on different halls. Interviews with two residents confirmed dissatisfaction with the food, citing that it was often cold and unpalatable. One resident, with diagnoses including major depressive disorder, schizoaffective disorder, and epilepsy, reported that the food was not always warm and tasted bad. Another resident, with bipolar disorder, major depressive disorder, type two diabetes, and schizoaffective disorder, stated that the food was frequently cold and could be better. The Food Service Manager attributed the temperature issues to frequent elevator breakdowns, which forced staff to carry food up the stairs, causing delays in meal delivery.
Failure to Maintain Elevator Results in Resident's Loss of Wheelchair Access
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition by not ensuring the consistent operation of the elevator. This deficiency was observed when the elevator became nonfunctional, preventing access between floors. As a result, a resident who is a bilateral knee amputee and relies on an electric wheelchair for mobility was unable to access their wheelchair while it was being repaired in the basement. The repair could not be performed in the resident's room or hallway, and the elevator outage meant the wheelchair remained inaccessible to the resident. The resident, who has a history of high blood pressure, chronic atrial fibrillation, and bilateral leg amputations, was left in bed without access to an appropriate alternative mobility device. The resident expressed frustration and distress about being confined to bed, especially given a previous prolonged period of immobility due to a wound. Staff interviews confirmed that the resident was offered a geri-chair, but it was not suitable due to the resident's lack of trunk control and the absence of a proper reclining or seatbelt-equipped chair to ensure safe positioning.
Failure to Maintain Proper Ventilation in Smoke Room
Penalty
Summary
The facility failed to maintain an appropriate exhaust system to remove cigarette smoke from the indoor smoke room, resulting in smoke and odor permeating areas frequented by residents and staff. Multiple observations over several days showed that residents and staff entered and exited the smoke room, with several residents smoking inside. The odor of smoke was detected from the lobby entrance, throughout the hallway, and inside and outside the 300 Hall dining room. On one occasion, a visible haze of smoke was observed outside the smoke room. Two floor fans and two garage fans intended to ventilate the area were not turned on during these observations. Interviews with residents, staff, and facility leadership confirmed the presence of smoke odor and visible smoke in the hallways and dining areas. One resident reported smelling smoke in their room when the door was open, and a housekeeper and CNA both noted strong smoke odors and visible smoke outside the smoke room. The Maintenance Director acknowledged that the fans should have been operating but were either turned off by residents or not functioning due to a power issue. The Administrator confirmed that the exhaust fans were broken and that the smoke odor was more pronounced during colder weather when more residents smoked indoors.
Failure to Maintain and Secure Corridor Handrails
Penalty
Summary
The facility failed to ensure that all corridors had handrails and that existing handrails were securely affixed to the walls, as observed during multiple walkthroughs. Specific deficiencies included missing handrails between rooms and common areas, around the perimeters of nurses' stations, and in various hallways across the 100, 200, 300, and 400 halls. Additionally, several handrails were found to be loose, broken, or pulled away from the wall. These issues were directly observed by surveyors at different times throughout the facility. Interviews with the Maintenance Director and the Administrator revealed that the facility was aware of the missing and damaged handrails. The Maintenance Director stated that handrails were checked every three months and acknowledged the absence of necessary replacement parts, as well as the ongoing process of replacing plastic handrails with wooden ones. Both the Maintenance Director and the Administrator were not fully aware of the requirement for handrails to be present outside nurses' stations and on both sides of all corridors used by residents. The facility's area audit and preventative maintenance inspection listed handrails as an item for staff to inspect, but deficiencies persisted.
Improper Catheter Care Without Physician Orders
Penalty
Summary
The facility failed to provide catheter care consistent with physician orders for a resident with a suprapubic catheter. The resident, who had diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and a history of urinary tract infections, did not have a physician order to flush the suprapubic catheter. Despite this, an LPN flushed the catheter due to clotting issues, which was not documented in the resident's Treatment Administration Record or progress notes for November and December 2024. The facility's policies require that catheter care, including flushing, be performed only under physician orders and documented accordingly. However, the resident's medical records showed no such orders or documentation of the flushing procedure. The resident later presented to the emergency room with pain at the suprapubic catheter site, which was suspected to be due to trauma or mechanical pain from the catheter manipulation rather than a urinary tract infection. Interviews with facility staff revealed that the LPN acknowledged flushing the catheter without a physician's order, and the Director of Nursing confirmed that such actions should be documented and only performed with proper orders. The incident highlights a failure to adhere to established protocols for catheter care, leading to potential harm to the resident.
Mismanagement of Resident Trust Funds
Penalty
Summary
The facility failed to ensure that personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for the residents. Specifically, the facility did not ensure that withdrawals for personal spending were authorized by the resident or their legal guardian and signed off by the appropriate facility staff. This deficiency affected three residents, all of whom had cognitive impairments and were listed as their own financial responsible parties despite having legal guardians. The facility's policy required that personal funds be safeguarded and used exclusively for the resident, with proper authorization and documentation, which was not followed in these cases. For Resident #36, a withdrawal of $2,000 was made without proper authorization, and the funds were used to purchase gift cards. The receipts for these purchases were not signed by the resident, and there was a discrepancy of $10 between the withdrawal and the receipt totals. Additionally, items purchased with another withdrawal of $1,000 were not found in the resident's possession, and the resident's inventory sheets were not updated. Similar issues were found with Resident #48, where a $2,000 withdrawal was used to purchase gift cards, and the receipts were not signed by the resident. Items purchased with another $1,000 withdrawal were also not found in the resident's possession, and the inventory sheets were not updated. Resident #26 also experienced similar issues, with a $2,000 withdrawal made without proper authorization and used to purchase items that were not found in the resident's possession. The facility's Financial Coordinator and Life Enrichment Director admitted to mixing up gift cards and receipts, leading to improper accounting of resident funds. The Administrator was unaware of these practices and expected proper authorization and accurate record-keeping for all transactions involving resident funds. The facility's failure to follow its own policies and procedures resulted in the mismanagement of resident funds and a lack of accountability for the purchases made with those funds.
Failure to Address Outstanding Checks in Resident Trust Fund
Penalty
Summary
The facility failed to ensure general accounting principles were followed by not addressing outstanding checks during monthly resident trust fund reconciliations. The facility's policy required the Resident Trust Clerk to void and reissue checks that were outstanding for over two months. However, a review of the facility's monthly resident trust reconciliation from April 2023 through March 2024 revealed multiple checks, some dating back to 2015, that remained outstanding. These checks ranged in amounts from $10.00 to $2,740.00, indicating a significant lapse in following the established procedures for managing resident trust funds. Interviews with the Financial Coordinator and the Administrator revealed that the monthly reconciliation was performed by an accountant from the facility's management company. The Financial Coordinator, who was responsible for factoring outstanding checks into the reconciliation, was not trained to investigate these checks and did not have the authority to void them. The Administrator expected the accountant to notify the Financial Coordinator of any issues, but there was no follow-up on the outstanding checks, leading to the deficiency in managing the resident trust funds properly.
Failure to Provide Homelike Environment and Maintain Cleanliness
Penalty
Summary
The facility failed to provide a homelike environment by serving meals on Styrofoam plates with plastic utensils, which was observed during multiple meal times. Residents expressed dissatisfaction with the use of these materials, stating that they would not use them at home and found them difficult to use. One resident, who had hemiplegia, struggled to eat with the plastic utensils, resulting in a significant portion of their meal being uneaten. Another resident, who was totally dependent on staff for eating, had difficulty consuming their meal as the plastic fork could not cut through the food properly. Staff interviews confirmed that the use of Styrofoam and plastic utensils was not considered homelike, and the Dietary Manager acknowledged that the dishwasher was fixed but residents were still using disposable items until she felt comfortable with the dishwasher's performance. The facility also failed to provide clean and properly maintained equipment. One resident was transferred to a new wheelchair that was visibly dirty, with white crusty and reddish-brown stains on the seat and thick cobwebs on the wheels. Staff interviews revealed that the night shift CNAs were responsible for cleaning wheelchairs, but the provided wheelchair was not cleaned before being given to the resident. The Director of Nurses stated that she expected staff to provide clean wheelchairs to residents. Additionally, the facility did not maintain clean resident rooms. Observations of three different rooms showed sticky floors, dirty privacy curtains with brown stains, dusty air conditioning units, and trash debris. One resident expressed distress over the state of their room, which had not been cleaned adequately. Staff interviews indicated that housekeeping was expected to follow cleaning schedules, but the observed conditions did not meet these expectations. The Housekeeping Supervisor and the Administrator both stated that they expected residents' rooms to be clean and orderly, but this was not the case during the survey observations.
Care Plan Deficiencies for Smoking and Medication Refusals
Penalty
Summary
The facility failed to ensure each resident's care plan was updated and accurate to reflect the resident's needs. This deficiency affected three residents whose care plans did not identify their smoking status and one resident whose care plan did not identify medication refusals. The facility's policy requires comprehensive care plans to be completed within 14 days of admission and baseline care plans within 48 hours of admission, with information gathered from direct observation, communication with the resident, and input from the interdisciplinary team (IDT). However, these requirements were not met for the affected residents. Resident #283, who has diagnoses including high blood pressure, COPD, and a history of stroke, was observed smoking multiple times in the facility's smoking area. Despite this, the resident's care plan did not include any information about their smoking status. Interviews with facility staff confirmed that the resident is a smoker and that smoking should be included in the care plan to ensure staff are aware of the resident's specific health conditions. Resident #65, who has diagnoses including hemiplegia, multiple sclerosis (MS), and high blood pressure, had a history of medication refusals documented in their progress notes. Despite this, the resident's care plan did not address medication or treatment refusals. Interviews with facility staff confirmed that the resident frequently refuses medications and treatments, and this information should be included in the care plan to direct staff approaches during medication administration and treatments. Additionally, Residents #64 and #18, both listed as smokers, were observed smoking in the facility's smoking area, but their care plans did not address their smoking status. Interviews with the MDS Coordinator, DON, and Administrator confirmed that smoking and medication refusals should be included in the care plans to address each resident's unique health concerns.
Failure to Assess and Investigate Falls, Use Functional Equipment, and Apply Gait Belts Properly
Penalty
Summary
The facility failed to appropriately assess and investigate a series of falls resulting in head injuries for one resident. The resident experienced multiple falls, each resulting in head injuries, but the facility did not document investigations regarding the specific circumstances of these falls or hold care plan meetings to discuss fall interventions. Additionally, the resident's care plan did not identify the resident's transfer status, behavior of lowering him/herself to the floor, or updated interventions following the falls, such as the use of a low bed and fall mat. The facility also failed to ensure appropriate techniques and functional equipment were utilized during mechanical lift transfers for two residents. One resident reported feeling unsafe using a broken sit-to-stand lift, which staff continued to use despite its malfunctioning legs. Observations confirmed that staff manually pushed the lift's legs open, and the lift was wobbly. Another resident was transferred using a Hoyer lift without the wheelchair brake being locked, and the wheelchair was tilted backward, posing a safety risk. Furthermore, the facility did not ensure staff applied and used gait belts properly during transfers or assisted ambulation for three residents. Observations showed that staff lifted residents under their arms without using gait belts, and one resident's gait belt was left too loose during ambulation. Additionally, the facility failed to ensure residents were routinely and accurately assessed for smoking safety for three residents, as required by their policy.
Failure to Assess Side Rail Safety
Penalty
Summary
The facility failed to ensure that residents using side rails were appropriately assessed for safety in accordance with the facility's policy. This deficiency was observed in four residents, who were not properly evaluated for the risks and benefits of side rail use. The facility's policy mandates that all residents using side rails must have a Restraint/Entrapment Assessment completed upon initial use, quarterly, and as needed if there is a significant change in the resident's condition. However, these assessments were either missing or incomplete for the residents in question. Resident #125, who had severe cognitive impairment and physical limitations due to a stroke, was observed with side rails raised on multiple occasions. Despite this, there were no entrapment or side rail assessments found in the resident's medical record, and the care plan did not identify the use of side rails. Interviews with CNAs revealed that they were unsure why the resident had side rails and indicated that nurses were responsible for informing them about such interventions. Similarly, Resident #36, who had severe cognitive impairment and multiple physical disabilities, was observed with a U-shaped rail raised on the bed. The entrapment assessment for this resident was incomplete, and the care plan did not document the use of side rails. Interviews with CNAs and the DON indicated that side rails were added during a recent hospitalization without proper assessment. Residents #30 and #46 also had incomplete or outdated assessments, and their care plans did not reflect the use of side rails. Staff interviews revealed a lack of clarity on the frequency and responsibility for conducting these assessments, highlighting a systemic issue in the facility's adherence to its own policies.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation for two out of three medication carts reviewed. Specifically, the controlled substance count sheets for the 400 and 300 halls showed that manual end-of-shift narcotic counts were not completed and documented per facility policy. For the 400 hall, the count was incomplete on multiple days in March and April, with some shifts not being counted at all. Similarly, the 300 hall had several days in April where the narcotic count was not completed for all shifts. This failure to adhere to the policy was confirmed through interviews with staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), all of whom acknowledged the requirement for narcotic counts to be conducted every shift, every day, with one oncoming and one off-going staff member participating in the count. The facility's Medication Storage and Destruction Policy mandates that a manual end-of-shift narcotic count be completed with the oncoming nurse counting and the outgoing nurse verifying. The policy also states that any nurse leaving the facility without properly conducting the narcotic count will face disciplinary action. Despite these clear guidelines, the review of the controlled substance count sheets revealed significant lapses in compliance. The DON confirmed that she expected the CMTs and nurses to follow the policy, but the records showed numerous instances where the counts were either partially completed or not done at all, indicating a systemic issue in maintaining accurate records for controlled substances.
Failure to Ensure Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food delivered to residents was palatable and at the required temperatures. Observations and interviews revealed that food served to residents in their rooms on the 300 and 400 hallways was often unappetizing, bland, and not at the proper temperatures. For instance, Resident #125, who is dependent on assistance with eating and has diagnoses including stroke and dysphagia, was served rubbery grits that could not be cut with a fork and pureed food that was unidentifiable and unpalatable. Resident #84, who requires setup or clean-up assistance with eating and has similar diagnoses, reported that the food was
Facility Fails to Maintain Kitchen Cleanliness and Ice Machine Safety
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, walk-in refrigerator, and bulk storage areas, as well as ensure the ice machine had an air gap. Observations on multiple dates revealed water pooling, trash, food debris, and grime in various areas of the kitchen and storage rooms. Specifically, the bulk storage room had water pooling and dirty lids on bulk bins, while the walk-in refrigerator had caked-on grime and food debris on the floor and shelves. The main kitchen area and pots room also had food debris and dried liquid stains. Additionally, the ice machine lacked an air gap, with its piping going straight into the drain, which could lead to contamination issues. Interviews with dietary staff and management confirmed that all dietary staff were responsible for cleaning duties, including deep cleaning the walk-in refrigerator, floors, and bulk bin room. The cook was specifically tasked with cleaning the deep fryer after each use. Despite these responsibilities, the observations indicated that the cleaning schedules and policies were not being followed. The Dietary Manager and Administrator both expressed expectations that the kitchen and appliances should be clean and that staff should adhere to the facility's cleaning policies and schedules. The Maintenance Director was unaware of the missing air gap in the ice machine and acknowledged the expectation for it to be present to prevent contamination.
Failure to Obtain and Document Necessary Medical Orders
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice by not obtaining necessary medical orders for a resident upon admission. Specifically, the facility did not obtain orders for Peripherally Inserted Central Catheter (PICC) line care and nephrostomy tube care. Additionally, the facility did not ensure that suprapubic catheter care orders were correctly documented in the Treatment Administration Record (TAR). This resulted in the resident not receiving appropriate care for these medical devices, as observed on multiple occasions when the resident did not have a dressing around the suprapubic catheter site. The resident in question had severe cognitive impairment and multiple medical conditions, including multiple sclerosis, seizures, high blood pressure, and schizophrenia. The resident was readmitted from the hospital with a urinary tract infection and bacteremia, and had a PICC line, nephrostomy tube, and suprapubic catheter in place. Despite these conditions, the facility failed to obtain and document the necessary care orders for these medical devices, leading to lapses in care. Furthermore, the facility did not complete a required yearly electrocardiogram (EKG) for the resident, who was on high-risk medications such as antipsychotics and antidepressants. The EKG was not performed due to a backlog with the EKG service provider. The Director of Nursing acknowledged that staff did not place the orders correctly in the computer system, which contributed to the failure in providing the required care and completing the EKG.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure residents who required assistance with activities of daily living (ADLs) received necessary services to maintain adequate personal hygiene. One resident was left soiled for an extended period, resulting in a saturated bedspread, blanket, and clothing, as well as a bright red and inflamed rash under the resident's pannus. The resident expressed not knowing when they were last assisted with changing their brief, and the Certified Nursing Assistant (CNA) confirmed the resident had likely been left wet the entire night and morning. The CNA also noted that staff are expected to check and change incontinent residents at least every two hours, but this was not done for this resident. The Certified Medication Technician (CMT) and Licensed Practical Nurse (LPN) provided conflicting information about the resident's ability to care for themselves and any refusals of care, indicating a lack of proper documentation and communication among staff. Three other residents were observed with poor personal hygiene, including unshaven faces with food particles in their beards and long, jagged nails with dark matter underneath. These residents had severe cognitive impairments and were dependent on staff for personal hygiene and other ADLs. The care plans for these residents indicated the need for assistance with personal hygiene, but observations showed that staff did not provide the necessary care. Interviews with staff revealed that residents' nails had not been clipped because nail clippers could not be found, and shaving and nail care were supposed to be completed on shower days but were not consistently done. The Director of Nursing (DON) confirmed that staff are expected to change soiled residents in a timely manner and document any behaviors related to refusals of incontinence care. The DON also stated that staff should shave and provide nail care on residents' shower days and as needed. However, the observations and interviews indicated that these expectations were not being met, leading to deficiencies in the care provided to the residents.
Failure to Identify and Treat Skin Issues
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards when staff did not identify newly acquired skin issues and obtain treatment orders for two residents. Resident #64, who has severe cognitive impairment and multiple diagnoses including multiple sclerosis and schizophrenia, was observed with an open area on the right anterior abdominal area. Despite multiple observations and interactions with staff, the open area was not documented, and no treatment orders were obtained. The resident's care plan did not address the skin condition, and there was no documentation in the progress notes or physician order sheets regarding the open area. Resident #44, who has mild cognitive impairment and diagnoses including viral hepatitis and schizophrenia, was found with a saturated incontinence brief and a bright red, inflamed rash under the abdominal fold. The resident was unaware of the rash, and there were no treatment orders or documentation of the rash in the progress notes or physician order sheets. Staff interviews revealed that aides are expected to report new skin issues to nurses, who should then call the physician for new orders, but this protocol was not followed. Interviews with staff, including an LPN and the DON, confirmed that weekly skin assessments are required and that any new skin issues should be reported immediately to obtain new orders. However, the facility did not adhere to these procedures, resulting in the failure to address the skin issues of the two residents in a timely and appropriate manner.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure that catheter bags remained positioned below the bladder and that catheter bags and tubing remained off the floor for two residents with indwelling urinary catheters. This failure was observed during multiple instances, including when CNAs were assisting residents with clothing changes and during Hoyer transfers. The improper handling of catheter bags and tubing created a potential for contamination and urinary tract infections (UTIs). The facility's Catheter Care policy, revised on 6/29/23, mandates that urinary drainage bags be kept below the level of the bladder and that they do not touch the floor, but these guidelines were not followed in the observed cases. Resident #64, who has moderate cognitive impairment and a supra-pubic catheter, was observed on two occasions where CNAs raised the urinary catheter bag and tubing above the resident's waist, causing cloudy urine to flow back towards the resident's abdomen. The resident's care plan included monitoring for signs of infection and ensuring proper catheter maintenance, but these protocols were not adhered to during the observed incidents. Resident #36, who has lower extremity impairment and uses a wheelchair, was observed with catheter tubing and bags frequently in contact with the floor. During a Hoyer transfer, the catheter bag was placed on the resident's stomach and later fell to the floor, with tubing dragging along the floor for approximately 50 feet. Multiple observations throughout the day showed catheter tubing coiled on the floor in various locations, including the resident's room and the dining room. Interviews with CNAs and nursing staff revealed a lack of understanding and adherence to proper catheter care procedures, contributing to the risk of infection for the residents involved.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that residents requiring dialysis had appropriate physician orders for assessment and monitoring of dialysis access sites and did not maintain ongoing communication with dialysis centers. This deficiency was identified for one resident out of a sample of two residents receiving dialysis. The facility's policy required ongoing assessment and monitoring of residents before and after dialysis treatments, including checking vital signs and assessing the vascular access site for signs of infection or complications. However, the facility did not have physician orders for pre and post-dialysis assessments for the resident, and there was a lack of documentation of these assessments in the resident's medical records for several months. The resident, who had moderate cognitive impairment and a diagnosis of end-stage renal disease, reported that upon returning from dialysis treatments, the facility staff did not assess their dialysis site or check their vital signs. Interviews with facility staff, including LPNs and RNs, revealed inconsistencies in the documentation and communication processes. Some staff mentioned that pre and post-dialysis assessments were documented on the Treatment Administration Record (TAR), while others stated that a new communication form was being used to document these assessments and communicate with the dialysis center. However, there was no evidence of consistent use of these forms or documentation in the resident's electronic medical record (EMR). The Director of Nursing (DON) confirmed that nurses were expected to assess residents before and after dialysis and document these assessments. The DON also mentioned that a new form had been introduced to facilitate communication with the dialysis center, but there was no evidence that this form was consistently used or that the information was uploaded into the resident's medical record. The lack of proper documentation and communication led to the deficiency in providing safe and appropriate dialysis care for the resident.
Infection Control Deficiencies in Peri-Care and Catheter Treatment
Penalty
Summary
The facility failed to follow acceptable infection control standards when providing peri-care for one resident and when providing treatment for a supra-pubic catheter for another resident. In the first instance, a CNA provided peri-care to a resident with severe cognitive impairment and multiple diagnoses, including diabetes and dementia. The CNA did not change gloves or perform hand hygiene after providing peri-care, and continued to touch clean items, dress the resident, and assist with a transfer while wearing the same soiled gloves. This was against the facility's policy, which mandates changing gloves and performing hand hygiene after providing peri-care and before touching clean items. In the second instance, an LPN provided treatment for a resident with a supra-pubic catheter and severe cognitive impairment. The LPN did not clean the scissors used to cut a dressing before applying it to the resident's catheter site. The scissors had been placed on the resident's bathroom sink, a potentially contaminated surface, before being used. This action was contrary to the facility's infection control policy, which requires cleaning equipment with antibacterial wipes before use in wound care. Interviews with staff, including another CNA and the DON, confirmed that the observed practices were not in line with the facility's infection control policies. Both the CNA and the LPN acknowledged that they should have changed gloves and cleaned equipment as per the guidelines. The DON reiterated the expectation for staff to follow proper infection control practices, including changing gloves and performing hand hygiene after providing peri-care and cleaning equipment before use in wound care.
Non-Functioning Call Light in Resident Room
Penalty
Summary
The facility failed to ensure that all call lights in the facility were in working order, including a visual notification above the door and an audible notification at the nurse's station. This deficiency was observed in one of 17 resident rooms surveyed, affecting one resident diagnosed with hemiplegia, pseudobulbar affect, multiple sclerosis (MS), and hypertension. The resident required moderate assistance from staff with dressing and bathing tasks and used a wheelchair for locomotion. Despite the resident's care plan indicating the need for a functioning call light due to fall risk and musculoskeletal status, the call light in the resident's room had been non-functional for about three weeks. The resident reported this issue to staff, but it remained unresolved, and the call light did not illuminate or provide an audible alarm at the nurse's station during multiple observations over several days. Interviews with facility staff, including a CNA, RN, Maintenance Director, and the Director of Nursing (DON), revealed that the non-functioning call light had not been properly reported or addressed. The CNA and RN were unaware of the specific call light issue in the resident's room, although they acknowledged that a call light on the same hall had been reported that day. The Maintenance Director confirmed that he had not been informed of the non-functioning call light prior to that day. Both the DON and Administrator stated that they expected all resident call lights to function normally and provide both visual and audible notifications. The lack of communication and follow-through in addressing the non-functioning call light led to the deficiency noted in the report.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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