Beth Haven Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Hannibal, Missouri.
- Location
- 2500 Pleasant Street, Hannibal, Missouri 63401
- CMS Provider Number
- 265108
- Inspections on file
- 23
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Beth Haven Nursing Home during CMS and state inspections, most recent first.
A resident, who was cognitively intact and valued making choices about food and drink, was verbally abused by an LPN after requesting coffee. The LPN refused the request, then confronted the resident in another wing, loudly yelling and pointing a finger in the resident's face in a demeaning manner. Multiple staff witnessed the incident and described the LPN's actions as verbal abuse, noting the resident's surprise and confusion.
A resident with multiple sclerosis experienced ongoing pain and discomfort due to the use of a manual wheelchair that was too small, which the resident had purchased independently. Despite reporting the issue to the DON and Social Services Director, and the facility's policy requiring accommodation of adaptive device needs, no timely occupational therapy evaluation or suitable replacement wheelchair was provided. Attempts to alleviate discomfort with a cushion were unsuccessful, and the resident continued to lack a properly fitting wheelchair.
The facility did not ensure proper coordination and communication with an external therapy provider, resulting in two residents not receiving agreed-upon therapy goals, implementation of at-home therapy programs, or necessary assistance with toileting and basic needs during therapy sessions.
The facility was cited for multiple deficiencies in food safety and sanitation practices. Observations revealed improper food storage, preparation, and service, with staff failing to follow hygiene protocols. The kitchen and dining areas had significant accumulations of debris and grease, and the facility's ice machine drains lacked necessary air gaps. Staff engaged in unsanitary practices, and cleaning schedules were not consistently followed.
The facility did not submit complete and accurate direct care staffing information to CMS through the PBJ for a specified period. The Administrator confirmed that the facility had not been submitting PBJ data, as the previous payroll clerk responsible had left, and the payroll service was expected to manage submissions.
The facility failed to ensure proper hand hygiene and infection control during resident care and medication administration, with staff not washing hands or changing gloves appropriately. Insulin administration procedures were not followed, as staff did not clean insulin pen tips before use. Additionally, the facility did not comply with TB testing requirements for employees, lacking documentation of two-step TSTs and annual testing. The facility also lacked a water management team and procedures to address Legionella risks.
The facility failed to provide residents with reasonable access to their personal funds on weekends. A resident reported being unable to access their funds during this time. The business office, which managed funds for 43 residents, was only open on weekdays, requiring residents to request funds in advance for weekend access. The facility did not provide a policy on the Resident Trust Fund, and the administrator was unaware of the requirement for access during typical banking hours.
The facility did not maintain a sufficient surety bond to protect the personal funds of 43 residents, with the bond amount being $25,000 instead of the required $39,000. Staff, including the Administrator, were unsure of who was responsible for managing the resident trust fund and ensuring the bond's adequacy.
The facility failed to develop comprehensive care plans for four residents, omitting critical elements such as dialysis care and the use of assistive devices like bed rails and mobility bars. Despite observations confirming the presence of these elements, the care plans did not reflect them, indicating a failure to adhere to the facility's policy.
The facility failed to follow professional standards, resulting in deficiencies for several residents. A resident did not receive ordered lab work, and there was missing documentation for wound care and blood glucose checks. Two residents had undocumented medication administrations, and another was not observed taking medications despite severe cognitive impairment. The DON was unaware of the extent of these documentation issues.
The facility failed to provide necessary incontinence and oral care for several residents. A resident with severe cognitive impairment did not receive proper perineal care or oral hygiene assistance. Another resident with similar needs was not cleaned properly and did not receive oral care due to staff constraints. A cognitively intact resident did not receive complete perineal care or oral hygiene, and another resident requiring substantial assistance was not cleaned adequately. Staff interviews confirmed the care expectations, which were not met.
The facility failed to ensure consistent documentation of code status for three residents, leading to discrepancies between residents' wishes and medical records. A resident's desire to be DNR was not reflected in their POS and EMR, while another resident's DNR status was not documented in their care plan or POS. A third resident's DNR status was indicated by a sticker and binder but not in their POS or face sheet. Staff relied on various sources for code status, contributing to inconsistencies.
The facility failed to secure harmful chemicals, leaving them accessible to residents. Observations revealed unsecured hazardous items, including cleaning sprays and chemicals, in various areas, such as the Gardens SCU and dining rooms. The administrator acknowledged that these items should be locked away.
The facility failed to serve meals according to the diet spreadsheet menu, resulting in residents not receiving the appropriate dietary items. Staff were unaware of specific dietary needs and did not have access to the diet spreadsheet menu, leading to the omission of required food items such as dinner rolls and pureed desserts.
The facility failed to serve food at safe and appetizing temperatures for residents on mechanical soft and pureed diets. Observations showed that food items were served at temperatures below the expected 135°F for hot foods and above 40°F for cold foods. The Dietary Manager confirmed the temperature expectations, but the facility did not meet these standards.
The facility failed to ensure outdoor garbage and grease containers were covered when not in use. A dumpster was found without a lid, and a grease container had its lid hanging off, with residue visible on the surrounding grass. The Dietary Manager and Administrator were unaware of these issues, and no staff were present in the area during the observation.
The facility failed to inspect bed frames, mattresses, and bed rails for potential entrapment risks for three residents. One resident with impaired cognition and two others with mobility issues were observed with bed rails or mobility bars, but no inspections were documented. The maintenance department was responsible for these inspections, which were expected to be done quarterly, but were not conducted.
The facility failed to maintain a pest-free environment in its kitchen and food storage areas. Observations showed open windows without screens, propped open doors, and uncovered dumpsters and grease containers, allowing potential pest entry. Mouse droppings and dead insects were found in various locations, indicating inadequate pest control measures. Interviews revealed a lack of awareness and reliance on glue traps, with a history of mouse issues.
A resident with multiple sclerosis experienced pain due to an ill-fitting wheelchair, which the facility failed to replace for six months. Additionally, another resident's call lights were repeatedly found out of reach, hindering their ability to request assistance. Staff interviews confirmed that call lights should always be accessible, and the Director of Nursing acknowledged the facility's responsibility to provide proper equipment and accessibility.
The facility failed to protect resident property, resulting in missing and damaged clothing items for three residents. Despite reporting the issues to staff, the facility did not locate or replace the items. Observations confirmed bleach stains and missing clothing, and the facility's policy on handling resident belongings was not effectively followed.
A resident with severe cognitive impairment was placed in a power recliner chair that functioned as an unintentional restraint, as they were unable to operate the chair's remote control to lower their feet. Staff confirmed the resident's inability to get up without assistance when the footrest was elevated, and there was no documented medical need or practitioner order for the restraint, violating the facility's policy.
The facility did not perform required Nurse Aide Registry checks for two newly hired employees, a Receptionist and a CMT, as documented in their files. The Human Resources staff was unaware of this requirement, and the administrator confirmed it was their responsibility to complete these checks.
The facility failed to ensure proper reconciliation of Schedule II through IV controlled substances, as evidenced by missing signatures on narcotic count sheets for several shifts. The review revealed multiple instances where either the on-coming or off-going nurse, or both, did not sign the narcotic count sheet, indicating that the shift-to-shift narcotic count was not completed by two qualified staff members. Interviews confirmed that without signatures, there was no way to confirm if the narcotic counts were conducted.
The facility failed to administer insulin correctly for two residents, leading to significant medication errors. An LPN and a CMT did not prime insulin pens before administration, and the CMT did not hold the pen against the resident's skin for the required time. Both residents had diabetes and were prescribed specific insulin doses. The DON confirmed the correct procedure was not followed.
The facility failed to ensure discontinued medications for a resident and medications for two discharged residents were destroyed or returned to the pharmacy timely. A Lantus insulin pen remained in the medication cart long after discontinuation, and a Prevnar20 vaccine and other medications were found in storage after residents were discharged. Staff were unaware of why these medications were not handled appropriately, and the DON confirmed the responsibility of nursing staff to manage such medications promptly.
The facility did not post daily staffing information for four days, as required by its policy. Observations showed no staffing sheets in visible areas, with information only found in a binder in the locked SCU. Interviews with staff confirmed the lack of compliance, with the Director of Nursing and Administrator acknowledging the requirement to post staffing details outside the Social Services door.
The facility did not ensure that the most recent survey results were accessible to residents and visitors. The survey results were placed in a location that was not easily visible, especially for residents in wheelchairs, and the signage was positioned too high. Residents and a family member were unaware of where to find the survey results, and the resident council confirmed the lack of awareness. The Administrator admitted the need for better signage and accessibility.
A resident with severe cognitive impairment and fragile skin was improperly transferred using a gait belt instead of a mechanical lift, as required by their care plan. Two CNAs, unaware of the resident's transfer needs, used a gait belt, resulting in the resident's feet dragging on the floor. The DON confirmed the resident should have been transferred with a mechanical lift, and the bruises observed on the resident's arms were likely due to the improper transfer.
The facility failed to investigate allegations of abuse and misappropriation involving three residents. A resident reported being slapped by a staff member, but the DON did not pursue further investigation. Two residents reported issues with pain medication administration, with discrepancies in documentation by an LPN. The facility's investigation lacked written statements, and results were not reported to the state agency in time.
The facility failed to maintain effective pest control, leading to mice and roaches in the east dining room and kitchen. A resident was observed eating in a dining room with a roach-infested refrigerator. Mouse droppings and debris were found in the kitchen's dry storage room. Staff were unaware of the pest issues, and the Administrator noted previous measures to store food in bins had lapsed.
An LPN in a facility misappropriated narcotics from two residents, one of whom was alert and denied receiving the medication, while the other experienced severe pain due to a missed dose. The LPN, on probation for a similar past incident, failed to follow protocols requiring a second staff member to sign out PRN narcotics.
The facility failed to document the administration of controlled medications properly, leading to discrepancies in medication records for multiple residents. Medications were removed from the Nexus machine without proper documentation of administration or destruction, and some were removed without a physician's order. Staff interviews revealed that medications were sometimes left in carts, contrary to policy.
A resident with severe cognitive impairment and fragile skin was improperly transferred by staff using a gait belt and lifting under the arms, contrary to facility policy. This resulted in multiple bruises and skin tears. The resident's care plan required protective measures and mechanical lift use, but staff failed to adhere to these guidelines, as confirmed by interviews with CNAs and facility leadership.
A resident with arthritis and Alzheimer's was not provided with necessary adaptive eating equipment, such as a divided plate and curved utensils, despite being identified as needing them. Observations showed the resident struggled to eat without these aids, and staff interviews confirmed the oversight. The facility's dietary staff did not consistently follow dietary cards, leading to the deficiency.
Verbal Abuse of Resident by LPN Over Coffee Request
Penalty
Summary
A resident with diagnoses including nonrheumatic aortic valve stenosis, muscle weakness, and a history of falls, who was cognitively intact and able to make their needs known, requested a cup of coffee from an LPN. The LPN refused to provide the coffee, stating they would not make a cup just for the resident. The resident then went to another wing to seek assistance from other staff, expressing that it was important for them to make choices regarding food and drink. Upon learning that the resident had received coffee from another nurse, the LPN pursued the resident to the other wing, loudly and angrily confronting the resident in front of staff and other residents. Multiple witnesses reported that the LPN pointed their finger in the resident's face, yelled that the resident could not have coffee, and insisted that the resident was to listen to the LPN's instructions. The resident appeared surprised and expressed confusion about what they had done wrong. Staff present described the LPN's behavior as verbally abusive, noting the volume, tone, and physical proximity during the confrontation. Facility staff, including CNAs and a GPN, corroborated the account of the LPN's loud and demeaning behavior, with statements indicating that the LPN's actions were considered verbal abuse. The incident was reported to the Director of Nursing, who initiated an investigation. The facility's policy on abuse and neglect emphasized residents' rights to be free from abuse, including verbal abuse, but did not provide a specific definition of verbal abuse. The events described constituted a failure to protect the resident from verbal abuse by staff.
Failure to Provide Properly Fitting Wheelchair for Resident with MS
Penalty
Summary
The facility failed to ensure that a resident with multiple sclerosis had a properly fitting wheelchair that did not cause pain or discomfort. The resident, who was cognitively intact and dependent on staff for transfers, used a manual wheelchair that was too small and caused significant discomfort, particularly due to the resident's condition which resulted in one hip being higher than the other. The resident had purchased the wheelchair independently upon admission, without adequate guidance, and later reported that the chair was too short and painful to use. Despite the resident's complaints and the facility's policy requiring ongoing evaluation and accommodation of adaptive device needs, there was no documentation of an alternative plan or timely evaluation for a new wheelchair. The resident's care plan emphasized the need for physical comfort and maintenance of function within the limits of progressive MS, but the facility did not arrange for an occupational therapy evaluation or provide a suitable replacement wheelchair. Attempts to address the discomfort by providing a cushion were unsuccessful, as the cushion exacerbated the problem due to the chair's improper size. Interviews with facility staff, including the DON and Social Services Director, confirmed awareness of the resident's discomfort and the facility's responsibility to provide appropriate equipment. However, the Social Services Director had not successfully scheduled an occupational therapy evaluation, and the resident continued to lack a properly fitting wheelchair. The deficiency remained uncorrected from a previous survey, with no evidence of effective action taken to resolve the resident's ongoing discomfort.
Failure to Coordinate and Communicate with Therapy Provider
Penalty
Summary
The facility failed to ensure that residents received physical, occupational, and speech therapy services through a properly coordinated arrangement between the facility and the external therapy provider. This deficiency was identified through interviews and record reviews, which revealed a lack of communication and coordination between the facility and the therapy provider. As a result, there was no agreement on therapy goals, and the facility did not ensure that residents' at-home therapy programs were implemented while in the facility. Additionally, residents did not receive necessary assistance with toileting and basic needs during therapy sessions. These failures affected two residents who were receiving outpatient therapy services at the time, in a facility with a census of 65.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, and service, failing to adhere to professional standards for food safety. Observations revealed that food items were not securely sealed, labeled, or stored according to manufacturer's instructions, and raw meats were improperly thawed. Additionally, staff did not practice proper hand hygiene, glove usage, or hair restraint, and personal food and beverages were consumed in food preparation areas. Surfaces and equipment were not maintained free from grease and debris, and proper sanitization procedures were not demonstrated, with staff unsure of chemical sanitizer levels. Further observations highlighted unsanitary conditions in the storage and handling of dishes and utensils. The facility's ice machine drains lacked an air gap, posing a risk of backflow contamination. The kitchen and dining areas were found to have significant accumulations of food debris, grease, and trash, with equipment and surfaces not properly cleaned or maintained. The dietary manager acknowledged these issues, noting that cleaning schedules were not consistently followed, and external companies were relied upon for certain cleaning tasks. Staff were observed engaging in unsanitary practices, such as failing to wash hands after handling dirty items, touching personal items, and not using proper hair restraints. The dietary manager confirmed that staff should not eat or drink in food preparation areas and should follow proper handwashing protocols. The facility's maintenance supervisor and administrator were unaware of the lack of air gaps in the ice machine drains, which are necessary to prevent potential contamination.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) for the period from July 1, 2024, to September 30, 2024. This deficiency was identified during a review of the CMS PBJ Staffing Data Report dated January 28, 2025, which showed that the facility did not report staffing data for the specified period. During an interview on February 5, 2025, the Administrator acknowledged that the facility had not been submitting their PBJ information. The responsibility for submission was previously held by a payroll clerk who had since left employment, and the facility's payroll service was supposed to handle the PBJ submissions once their contract began.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices among staff during resident care and medication administration. Observations revealed that staff did not wash their hands or change gloves appropriately after direct contact with residents, particularly during personal care activities such as toileting and dressing. For instance, a CNA was observed assisting a resident with incontinence care without washing hands or changing gloves between tasks, and another CNA failed to perform hand hygiene after removing gloves. These lapses in hand hygiene were confirmed by staff interviews, where CNAs acknowledged the need for handwashing but admitted to not following the protocol. Additionally, the facility did not adhere to proper procedures for insulin administration. Staff were observed failing to clean the tips of insulin pens with alcohol before attaching needle caps and administering insulin to residents. This was a repeated issue among different staff members, who either forgot or were unaware of the requirement to disinfect the insulin pen tips. Interviews with the staff involved confirmed these oversights, and the DON expressed expectations for proper disinfection and glove use during insulin administration. The facility also failed to comply with tuberculosis (TB) testing requirements for employees. Several employee files lacked documentation of a two-step Tuberculin Skin Test (TST) prior to employment, and annual TB testing was either not completed or not documented correctly in millimeters of induration. The administrator acknowledged the oversight, attributing it to recent staff turnover in the Infection Preventionist position, which led to lapses in tracking and administering TB tests. Furthermore, the facility did not have an active water management team or a detailed water flow map to address Legionella risks, and the Maintenance Director was unaware of the necessary procedures to prevent waterborne pathogens.
Lack of Weekend Access to Resident Funds
Penalty
Summary
The facility failed to ensure residents had reasonable access to their personal funds, particularly on weekends. This deficiency was identified during an interview with a resident who reported being unable to access their funds on weekends. The facility managed funds for 43 residents, and the business office, responsible for handling these funds, was only open Monday through Friday from 8:00 A.M. to 4:00 P.M., with no banking hours on Saturdays. Residents were required to request funds in advance if they needed access on weekends. The facility did not provide a policy regarding the Resident Trust Fund when requested, and the administrator was unaware that residents should have access to their funds during typical banking hours.
Inadequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond to protect the personal funds of 43 residents held in the resident trust fund account. The facility's surety bond was $25,000, while the average monthly balance of the residents' personal funds required a bond of at least $39,000. The facility census was 71. During interviews, staff members, including the Admissions/Social Services staff, Accounts Receivable staff, and the Administrator, were unsure of who was responsible for managing the resident trust fund and ensuring the adequacy of the surety bond. The Administrator admitted to not reviewing the bond to confirm its adequacy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for four residents, as required by their policy. Resident #47, who had been on dialysis for about three years, did not have any focus, goal, or intervention for dialysis care in their care plan, despite having a physician's order for follow-up with a nephrologist during dialysis days. This oversight was confirmed during an interview with the resident, who stated they attended dialysis treatment three times weekly. Resident #68, who had severely impaired cognition and was dependent on staff for mobility, had a care plan that did not address the use of side rails, despite observations showing the resident in bed with bilateral 1/4 rails in the upright position. Similarly, Residents #14 and #10, both of whom had mobility issues and were at risk for falls, had care plans that failed to address the use of bed mobility bars, even though observations confirmed the presence of these bars on their beds. Interviews with the Care Plan/MDS Coordinator, the DON, and the Administrator revealed that care plans should reflect the care needs of residents, including the use of assistive devices like bed rails and mobility bars, as well as specific treatments like dialysis. The lack of documentation for these elements in the care plans indicates a failure to adhere to the facility's policy of developing and implementing comprehensive, person-centered care plans.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of practice for several residents, resulting in multiple deficiencies. For Resident #55, the facility did not obtain necessary lab work, including Hemoglobin A1c, CBC, and CMP, as ordered by the physician. Additionally, there was a lack of documentation for wound care treatments and blood glucose checks on several occasions. The Care Plan/MDS coordinator acknowledged the oversight in tracking lab orders and had only recently begun addressing this issue. Resident #46 experienced similar issues with missing documentation for medication administration and wound care treatments. The MARs for December 2024 and January 2025 showed multiple instances where doses of clonazepam and Tylenol were not documented as administered. The resident's care plan indicated the need for these medications to manage anxiety and pain, yet the facility failed to ensure consistent documentation and administration. Resident #19 also faced deficiencies in medication administration, with missing documentation for lorazepam doses in both December 2024 and January 2025. Furthermore, Resident #65, who had severe cognitive impairment, was not observed taking medications during a medication pass, contrary to facility policy. The Director of Nursing expressed expectations for staff to follow physician orders, complete treatments, and document all actions, but was unaware of the extent of missing documentation in the MARs and TARs.
Deficiency in Incontinence and Oral Care
Penalty
Summary
The facility failed to provide necessary care and services for incontinence and oral care for several residents. Resident #43, who had severe cognitive impairment and was dependent on staff for toileting and personal hygiene, was observed not receiving proper perineal care. The CNA assisting the resident did not clean the resident's front genital area and failed to offer or assist with oral care, despite the resident's care plan indicating the need for such assistance. Resident #46, also with severe cognitive impairment and dependent on staff for personal hygiene, was observed with a saturated incontinence brief. The CNA and LPN assisting the resident did not clean the resident's front genitalia and did not provide oral care. The CNA admitted to not providing oral care due to working alone and trying to get residents to breakfast. Resident #5, who was cognitively intact but dependent on staff for toileting, was observed not receiving complete perineal care. The CNA did not cleanse all areas of the resident's skin in contact with urine and did not offer or perform oral care. Additionally, Resident #175, who required substantial assistance with toileting, did not receive proper perineal care as the CNA did not clean the resident's front perineal area. Interviews with staff confirmed the expectations for perineal and oral care, which were not met in these instances.
Inconsistent Documentation of Code Status for Residents
Penalty
Summary
The facility failed to ensure that the medical records accurately and consistently indicated the residents' code status for three residents out of a sample of 18. This deficiency was identified through observation, interviews, and record reviews. For Resident #7, there was a discrepancy between the resident's wishes and the documented code status. The resident was cognitively intact and expressed a desire to be a Do Not Resuscitate (DNR), but the Physician Order Sheet (POS) and Electronic Medical Record (EMR) indicated a Full Code status. The resident's care plan and the code status binder, however, showed a DNR status, highlighting inconsistencies in documentation. Resident #31's records also showed inconsistencies. The face sheet and POS did not document any code status, while a purple heart sticker on the resident's name plate indicated a DNR status. The resident and their Power of Attorney confirmed the resident's wish to be a DNR, but this was not reflected in the care plan or POS. This lack of documentation could lead to confusion in an emergency situation. For Resident #46, the annual Minimum Data Set (MDS) indicated severe cognitive impairment, and the resident's Durable Power of Attorney (DPOA) was responsible for decisions. The POS and face sheet lacked documentation of the resident's code status, although a purple heart sticker and the code status binder indicated a DNR. The care plan confirmed the DNR status, but the EMR did not reflect this. Interviews with staff revealed a reliance on various sources for code status information, including name plates, binders, and EMRs, which contributed to the discrepancies observed.
Failure to Secure Harmful Chemicals in Facility
Penalty
Summary
The facility failed to ensure that harmful chemicals were kept in locked cabinets and were not accessible to residents. During an observation of the dietary and sanitation areas, several hazardous items were found unsecured in various locations within the facility. In the Gardens Special Care Unit, which caters to residents with dementia, an unlabeled cup with a pink paste, another with a blue liquid, and three cans of heavy-duty cleaning spray were found in an unlocked cabinet. Additionally, a gallon jug of concentrated descaler and delimer was found on an open shelf, and its label warned of severe skin burns and eye damage. In the west dining room, a can of disinfectant and sanitizing spray was found in an unlocked cabinet, and in the west kitchenette, a can of stainless steel cleaner and polish was similarly unsecured. Lastly, a can of furniture polish spray was found in an unlocked cabinet in the Helping Hands dining room. The facility's administrator acknowledged that cleaning supplies and chemicals should be secured and inaccessible to residents.
Failure to Follow Diet Spreadsheet Menu
Penalty
Summary
The facility failed to meet the nutritional needs of its residents by not adhering to the diet spreadsheet menu during meal preparation and service. On the specified date, the facility was observed to have not served dinner rolls, soft dinner rolls, pureed dinner rolls, or pureed frosted chocolate cake to residents on regular, mechanical soft, and pureed diets, despite these items being listed on the diet spreadsheet menu. The dietary staff, including [NAME] L and [NAME] Z, prepared and placed food items onto trays but did not include the required items for the residents' specific diet orders. Interviews with staff revealed a lack of awareness and communication regarding the specific dietary needs of residents. [NAME] Z was under the impression that the pureed dessert was on a different cart, while Direct Service Aide J admitted to not knowing what items each resident should receive and not having access to a diet spreadsheet menu. The Dietary Manager confirmed that staff were expected to follow the physician-ordered diet orders and the diet spreadsheet menus, which was not done in this instance.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature and taste for residents on mechanical soft and pureed diets. The facility's recipe binders lacked recipes and associated temperature guidelines for specific food items such as mechanical soft or pureed potato salad, spinach, and pork loin. On the day of the survey, the facility substituted pork loin for pork schnitzel and German potato salad for regular potato salad without ensuring proper temperature guidelines were followed. Temperature logs showed that while cooking temperatures were adequate, the temperatures of the food items served to residents were not maintained at safe levels. Observations in the dining room revealed that the mechanical soft and pureed food items were served at temperatures below the expected 135 degrees Fahrenheit for hot foods and above 40 degrees Fahrenheit for cold foods. For instance, mechanical soft potato salad was served at 61.2 degrees Fahrenheit and tasted warm, while pureed spinach was served at 108.7 degrees Fahrenheit and tasted cool. Interviews with residents and the Dietary Manager confirmed that the expectation was for hot foods to be served at a minimum of 135 degrees Fahrenheit and cold foods at less than 40 degrees Fahrenheit. However, the facility failed to meet these standards, resulting in food being served at inappropriate temperatures.
Improper Disposal of Garbage and Grease
Penalty
Summary
The facility failed to ensure that outdoor garbage and grease collection containers were properly covered when not in use. During an observation, a dumpster was found to be approximately 25% full of trash without a lid on the top and front. Additionally, a grease container, about 90% full, had its lid hanging off to the side, with a water bottle floating on the grease surface. Residue was visible on the grass around the grease container. No staff were present in the area at the time of observation. Interviews revealed that the Dietary Manager was unaware of the grease container's lid issue and mentioned that the dumpster never had lids. The Administrator was also unaware that the new dumpster, received after changing garbage disposal companies, lacked the ability to close its openings. The grease container was periodically emptied by a contracted company.
Failure to Inspect Bed Safety Features for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment hazards for three residents. Resident #68, who had severely impaired cognition and was dependent on staff for mobility, was observed with bed rails in the raised position, yet there was no documentation of inspections for entrapment risks. Similarly, Resident #14, who was cognitively intact but required substantial assistance with mobility and had a history of falls, was observed with mobility bars on the bed without any record of inspection for potential entrapment. Resident #10, also cognitively intact but dependent on staff for bed mobility and at risk for falls, was observed with mobility bars on the bed, again with no evidence of inspection for entrapment risks. Interviews with the Maintenance Director and the Director of Nursing revealed that the maintenance department was responsible for measuring entrapment zones, but these measurements were not being conducted. The Administrator expected these measurements to be completed quarterly, indicating a lapse in the facility's maintenance program.
Pest Control Deficiency in Facility's Food Areas
Penalty
Summary
The facility failed to maintain an environment that deters pests from entering critical areas such as the kitchen, satellite dining rooms, kitchenettes, and food storage areas. Observations revealed that windows in the kitchen were open without screens, and an exterior door near the dumpster and grease collection container was propped open, allowing potential pest entry. The dumpster was partially full and uncovered, and the grease container was nearly full with its lid hanging off. Additionally, the door to the emergency food/water storage and dietary walk-in cooler and freezer room was propped open, further compromising the facility's pest control measures. Mouse droppings were found in various locations, including a laundry basket near bulk bins of rice and oats, around boxes of fry oil, and on the floor and shelves in the dry storage room. Dead insects resembling cockroaches were also found in the kitchenette near the east dining room. Interviews with the Dietary Manager and Administrator revealed a lack of awareness and inadequate pest control measures, such as missing dumpster lids and reliance on glue traps provided by the pest control company. The facility had a history of mouse issues, and maintenance staff had not yet replaced damaged windows or installed screens.
Deficiencies in Wheelchair Fit and Call Light Accessibility
Penalty
Summary
The facility failed to provide a properly fitting wheelchair for a resident with multiple sclerosis, leading to discomfort and pain. The resident, who was tall and used a manual wheelchair, was observed sitting awkwardly in a chair that was too small, causing pain in the right hip. Despite being aware of the issue, the Care Plan/MDS Coordinator acknowledged that the process to obtain a suitable wheelchair had been ongoing for six months without resolution. The facility lacked a specific staff member responsible for acquiring necessary equipment, and the absence of a therapy department further complicated the situation. Another deficiency was identified when a resident's call lights were consistently found out of reach, compromising the resident's ability to request assistance. The resident, who had moderately impaired cognition and required assistance with mobility, was observed multiple times with call lights either wrapped around a wall outlet or lying on the floor, making them inaccessible. Interviews with staff, including an LPN and a CNA, confirmed that call lights should always be within reach of residents. The Director of Nursing acknowledged the facility's responsibility to ensure residents have proper equipment and that call lights are accessible. However, the lack of a designated staff member to manage equipment needs and the absence of a therapy department contributed to the ongoing issues with the resident's wheelchair and the inaccessibility of call lights.
Failure to Protect Resident Property in Laundry Services
Penalty
Summary
The facility failed to ensure the protection of resident property, specifically clothing items sent to the laundry, resulting in missing and damaged items for three residents. Resident #4 reported missing ten pairs of gray socks and a cover-up, which were labeled with their name, and received items back with bleach stains. Resident #59 was missing several pairs of jogger pants, also labeled, and had no clean pants available, affecting their willingness to shower. Resident #67 reported missing three gray t-shirts, labeled with their name, which had been missing for several months. Interviews with the residents revealed that they had reported the missing items to CNAs and laundry staff, but the facility had not located or replaced the missing items. Observations confirmed the presence of bleach stains on Resident #4's clothing and the absence of pants for Resident #59. The laundry aide and housekeeping supervisor were unaware of the missing items and bleach stains, and the facility's process for handling missing items was not effectively communicated or executed. The facility's policy required staff to treat residents' belongings with respect and inventory them upon admission. However, the policy was not adequately followed, as evidenced by the lack of updated inventory lists and the failure to address residents' concerns about missing and damaged clothing. The Director of Nurses and Administrator acknowledged the expectation for residents to receive all their laundered items back and for the facility to replace any lost or damaged items, but these expectations were not met in practice.
Failure to Evaluate Recliner as Restraint for Resident
Penalty
Summary
The facility failed to evaluate the use of a power recliner chair as a restraint for a resident who was mentally and physically incapable of using the chair's remote control. The resident, who was severely cognitively impaired and had a history of traumatic brain injury, was observed in a reclined position with feet elevated, unable to lower them independently. The facility's policy on restraints requires that any device restricting a resident's movement be evaluated and documented, which was not done in this case. Observations showed the resident becoming restless and attempting to get up from the recliner with the footrest raised, indicating distress and an inability to move freely. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident could not operate the recliner control due to cognitive and physical limitations. The staff acknowledged that the recliner functioned as an unintentional restraint, as the resident could not get up without assistance when the footrest was elevated. The facility's policy clearly states that restraints should only be used for medical symptoms and not for staff convenience or fall prevention. However, there was no documentation of a medical need for the restraint, nor was there an order from a practitioner. The lack of assessment and documentation regarding the recliner's restraining properties led to the deficiency, as the resident was effectively restrained without proper evaluation or justification.
Failure to Conduct Nurse Aide Registry Checks for New Hires
Penalty
Summary
The facility failed to conduct necessary checks against the Nurse Aide Registry for two newly hired employees, which is a requirement to ensure that individuals with a Federal Indicator are not employed. The first case involved a Receptionist hired on 04/10/24, whose employee file lacked documentation of a completed Nurse Aide Registry check. Similarly, a Certified Medication Technician (CMT) hired on 01/26/24 also had no documentation of such a check in their file. During interviews, the Human Resources staff admitted to being unaware of the requirement to perform Nurse Aide Registry checks, while the administrator acknowledged the necessity of these checks and indicated that it was the responsibility of Human Resources to ensure they were completed.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper reconciliation of Schedule II through IV controlled substances, as evidenced by missing signatures on the narcotic count sheets for several shifts. The review of the narcotic count sheets for the [NAME] Unit, Team 1, revealed multiple instances where either the on-coming or off-going nurse, or both, did not sign the narcotic count sheet, indicating that the shift-to-shift narcotic count was not completed by two qualified staff members. This lack of documentation was confirmed by interviews with the LPN and the Director of Nursing, who both acknowledged that without signatures, there was no way to confirm if the narcotic counts were conducted. The facility also did not provide a policy regarding Controlled Substances or Narcotic Reconciliation when requested. During interviews, the Director of Nursing and the administrator both stated that two qualified staff members should conduct the narcotic counts together at each shift change and immediately sign the count sheet to document the completion of the count. The failure to adhere to these procedures resulted in a lack of accountability for the narcotic medications, which included Morphine sulfate, Hydrocodone, Alprazolam, Clonazepam, and Ativan.
Failure to Administer Insulin Correctly for Two Residents
Penalty
Summary
The facility failed to administer insulin according to the manufacturer's recommendations for two residents, leading to significant medication errors. Resident #22, who had a diagnosis of diabetes, was prescribed Humalog 75/25 Insulin, 40 units subcutaneously in the evening. During an observation, an LPN administered the insulin without priming the pen, which is a necessary step to ensure the correct dose is delivered. The LPN admitted to forgetting to prime the pen before administering the insulin. Similarly, Resident #20, also diagnosed with diabetes, was prescribed Lispro insulin, seven units three times daily. A CMT administered 40 units of insulin without priming the pen and did not hold the pen against the resident's skin for the required five seconds as per the manufacturer's instructions. The CMT was unaware of the need to prime the pen or the specific duration to hold the pen against the skin. The Director of Nursing confirmed that insulin pens should be primed with two units before preparing the ordered dose and held against the skin for five seconds during administration.
Failure to Timely Destroy or Return Discontinued and Discharged Residents' Medications
Penalty
Summary
The facility failed to ensure that discontinued medications for one resident and medications for two discharged residents were destroyed or returned to the pharmacy in a timely manner. For Resident #52, a Lantus insulin pen was found in the medication cart 153 days after the medication order was discontinued. The Certified Medication Technician (CMT) acknowledged that the insulin pen should have been removed and destroyed as soon as the order was discontinued, as the resident was no longer using insulin pens due to having an insulin pump. For Resident #301, a vial of Prevnar20 vaccine was found in the medication storage room refrigerator after the resident had been discharged. The CMT and Licensed Practical Nurse (LPN) interviewed were unaware of why the medication had not been returned to the pharmacy. Similarly, for Resident #300, medications including Ipratropium Bromide/Albuterol Sulfate nebulizer treatment and Miralax were found in the medication storage room after the resident had been discharged. The CMT did not know why these medications had not been sent home with the resident or returned to the pharmacy. The Director of Nursing (DON) confirmed that nursing staff was responsible for destroying or returning medications that were no longer in use immediately after the occurrence.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information for four consecutive days during the survey period, despite having a policy in place that requires such postings. The policy, last revised in August 2022, mandates that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing personnel responsible for resident care must be posted in a prominent location accessible to residents and visitors. This information should include the facility name, current date, resident census, shift schedule, and the total number of nursing staff working each shift. Observations during the survey revealed that no daily staffing sheets were posted in visible areas such as the vestibule, front hall, common areas, nursing stations, or outside office doors. Instead, a binder containing staffing information was found on a desk in the locked special care unit (SCU), inaccessible to residents and visitors. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the lack of compliance with the posting requirement. The LPN indicated that the charge nurse in the SCU was responsible for filling out the staffing sheet and placing it in a binder, but did not believe it was posted elsewhere in the facility. The Director of Nursing and the Administrator both stated that the daily staffing information should be posted outside the Social Services door for residents and families to view. The Administrator also confirmed that SCU staff were responsible for completing and posting the staffing sheet. This failure to post staffing information as required by the facility's policy constitutes a deficiency in compliance with regulatory standards.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to make the most recent survey results easily accessible to residents and visitors, as required. Observations revealed that the survey results were placed in a location that was not easily visible or accessible, particularly for residents in wheelchairs. A sign indicating the location of the survey results was posted on a bulletin board at the front entrance, but it was positioned higher than eye level, making it difficult to read. Additionally, the filing cabinets containing the survey results were located behind the nurse's station, with no visible signage directing residents or visitors to them. Interviews with residents and a family member confirmed that they were unaware of where to find the survey results, and the resident council meeting further highlighted that residents were not informed about the location of these documents. The Administrator acknowledged that the signage should be at eye level and that the results should be accessible for private review.
Improper Transfer Technique Used for Non-Weight Bearing Resident
Penalty
Summary
The facility failed to provide a safe transfer for a resident who was supposed to be transferred using a mechanical lift, as per their care plan. Instead, two CNAs used a gait belt to transfer the resident from a recliner to a wheelchair, despite the resident being non-weight bearing. This action was contrary to the facility's policy, which mandates the use of a mechanical lift for residents who cannot bear weight. The CNAs involved were not aware of the requirement to use a mechanical lift for this resident, indicating a lack of communication or training regarding the resident's care plan. The resident in question had a care plan that specified the use of a mechanical lift for transfers to prevent skin injury, as the resident had fragile skin and was at risk for skin tears. The resident's cognitive function was severely impaired, and they were diagnosed with Alzheimer's disease and dementia, requiring assistance with personal care and mobility. During the observed transfer, the resident's feet dragged on the floor, and they did not bear weight, which was inconsistent with the care plan and facility policies. Interviews with the staff revealed that there was a misunderstanding or lack of awareness about the resident's transfer requirements. One CNA mentioned that they were trained to use a gait belt and hook their arms under the resident's arms, which was not appropriate for this resident. The Director of Nursing confirmed that the resident should have been transferred with a mechanical lift and acknowledged that the bruises observed on the resident's arms were likely related to the improper transfer technique used by the staff.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation following allegations of abuse and misappropriation of narcotics involving three residents. Resident #2 reported being slapped on the hand by a staff member, which was corroborated by a Certified Nurse Assistant (CNA) who reported the incident to the Director of Nursing (DON). Despite the resident being cognitively intact and having a bruise on the hand, the DON did not pursue further investigation, as the resident later stated the bruise was self-inflicted. In another incident, Resident #1, who was also cognitively intact, reported not receiving a prescribed pain medication, which was documented as administered by an LPN. Similarly, Resident #3, with moderate cognitive impairment, reported severe pain and did not receive a scheduled dose of pain medication, although the narcotic count sheet indicated it was removed by the same LPN. The facility's investigation lacked written statements from staff or residents, indicating an incomplete investigation process. The DON admitted to not obtaining necessary documentation or conducting thorough interviews, citing inexperience with such investigations. The facility also failed to report the investigation results to the state agency within the required timeframe. The administrator acknowledged the expectation for a comprehensive investigation, including obtaining written statements, which was not fulfilled.
Pest Control Deficiency in Dining and Kitchen Areas
Penalty
Summary
The facility failed to maintain effective pest control measures, resulting in the presence of mice and roaches in critical areas such as the east dining room and the kitchen. Observations revealed that a resident was eating breakfast in the east dining room where a refrigerator contained eight to ten small insects resembling roaches. A Certified Nurse Assistant confirmed that the dining room had been treated for roaches the previous day, but was unaware of the infestation inside the refrigerator. Residents had also complained about the presence of roaches in the facility. Further observations in the kitchen's dry storage room revealed mouse droppings on the floor under a metal shelving unit, along with brown debris, loose dry pasta, and crackers. A bag of corn bread mix was found on the floor near the droppings. Interviews with dietary staff indicated a lack of awareness regarding the mouse droppings and the cleanliness of the storage area. The facility's pest control company and the Maintenance Director highlighted that food on the floor serves as a food source for pests, and the east dining room was supposed to be closed to residents due to recent roach treatment. The Administrator acknowledged previous issues with mice and the need for dry storage items to be stored in plastic bins, but was unsure why this practice had ceased.
Misappropriation of Narcotics by LPN
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their medications by an LPN. The LPN was found to have signed out narcotics for a resident who was alert and oriented, yet the resident denied receiving the medication. This incident was discovered when the resident, who was cognitively intact, reported not having requested or received the pain medication that was documented as administered by the LPN. The resident's medical records and narcotic count sheets confirmed the discrepancy, as there was no evidence of a pain complaint or request for medication on the day in question. Another resident, who had moderate cognitive impairment, was also affected by the LPN's actions. The LPN removed a narcotic from the count sheet but failed to document its administration on the Medication Administration Record (MAR). This resident later complained of severe pain, suggesting that the scheduled dose of pain medication was not administered. The LPN was on probation for a previous incident involving missing pain medication and was required to have another staff member sign out any PRN narcotics, a protocol that was not followed. The facility's Director of Nursing and other staff members, including a Certified Medication Technician and a House Supervisor, identified these discrepancies during their investigation. The LPN exhibited suspicious behavior, such as excessive sweating, and was sent home on the day of the incident. The LPN was subsequently terminated due to the misappropriation of narcotics and failure to adhere to established protocols, which had been previously addressed with a verbal warning.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to properly document the administration of controlled medications for several residents, leading to discrepancies in medication records. For Resident #13, there were multiple instances where hydrocodone/acetaminophen and lorazepam were removed from the Nexus machine, but the administration was not documented on the Medication Administration Record (MAR). Additionally, there were occasions where medications were signed out by one staff member but administered by another, without proper documentation of the administration or destruction of the medication. Resident #15's records showed similar issues, with Ativan being removed from the Nexus machine but not documented as administered on the MAR. There were also instances where more medication was removed than documented as administered, and some doses were not accounted for in terms of administration or destruction. This pattern of inadequate documentation and medication handling was also observed with Resident #11, where tramadol was removed but not documented as administered. Furthermore, Resident #16 had tramadol removed from the Nexus machine without a physician's order, and there was no documentation of its administration. Interviews with staff revealed that medications were sometimes removed early and left in medication carts, which is against the facility's policy. The Assistant Director of Nursing confirmed that medications should not be left in cups in the cart and must be double-locked if not administered immediately.
Inappropriate Transfer Techniques Lead to Resident Injuries
Penalty
Summary
The facility failed to provide safe transfers and prevent bruising and skin tears for a resident identified as at risk for such injuries. The resident, who had severe cognitive impairment and was dependent on staff for mobility and personal care, was observed being transferred by staff using inappropriate techniques. Staff lifted the resident under the arms with a gait belt, contrary to the facility's policy that manual lifting should be eliminated when feasible and that a mechanical lift should be used for total body lifts. This improper handling led to multiple bruises and skin tears on the resident's fragile skin. The resident's care plan indicated a high risk for skin integrity issues, requiring the use of protective measures such as tubigrip sleeves and sheep's wool padding. Despite these precautions, staff were observed pulling on the resident's arms while dressing and undressing, which contributed to the skin injuries. The resident's medical history included conditions such as arthritis, muscle weakness, and Alzheimer's disease, which necessitated careful handling to prevent further harm. Interviews with staff revealed a lack of adherence to the facility's safe lifting policy. CNAs admitted to lifting the resident under the arms and acknowledged that the resident did not bear weight during transfers, which should have been performed using a mechanical lift. The Assistant Director of Nursing and the Administrator confirmed that lifting under the arms with a gait belt was inappropriate and could cause injuries, yet this practice was observed during the survey.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for Resident #9, who was identified as needing these items to assist with eating and drinking. The resident had diagnoses of arthritis, muscle weakness, Alzheimer's disease, and required assistance with personal care. The care plan specified the need for a divided plate, curved utensils, and Kennedy cups at all meals to facilitate eating and drinking. However, during observations, the resident was not provided with these adaptive devices, and the food was not served in the required consistency. During breakfast, the resident was served food on a regular plate with flat silverware, and no Kennedy cup was provided. The resident struggled to eat, using fingers to pick up food and attempting to drink milk with a spoon. The CNA supervising breakfast acknowledged the absence of adaptive utensils and was unaware of their location. At lunch, the resident was again served food without the necessary adaptive equipment, and a family member had to assist in cutting the food. Interviews with staff, including the Dietary Supervisor and the Assistant Director of Nursing, confirmed that adaptive equipment should have been provided according to the dietary cards. The Dietary Supervisor admitted that dietary staff were not consistently following the dietary cards, and the Assistant Director of Nursing emphasized the importance of providing assistive devices to prevent choking and facilitate eating. The Administrator also stated that staff should ensure dietary requirements are followed and adaptive equipment is provided as indicated.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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