Bridgewood Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 11515 Troost, Kansas City, Missouri 64131
- CMS Provider Number
- 265822
- Inspections on file
- 65
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 29 (3 serious)
Citation history
Health deficiencies cited at Bridgewood Health Care Center during CMS and state inspections, most recent first.
Multiple residents with psychiatric and behavioral histories engaged in separate resident‑to‑resident physical altercations, despite an abuse policy prohibiting willful infliction of harm. In one event, a resident on 1:1 observation verbally argued with another resident in a hallway, threatened to kick the peer, then kicked the peer’s leg; the second resident responded by punching the first in the head, causing head swelling and a hand injury. In another event, a behaviorally escalated resident left an assigned unit against direction and, while upset about access restrictions and peer issues, kicked a cognitively impaired peer in the shin. In a third incident, two cognitively intact residents with psychiatric diagnoses bumped into each other, exchanged words, raised fists, and one intentionally struck the other in the face, causing facial scratches and a fall against a wall before CNAs could intervene. These episodes were substantiated as intentional, non‑accidental resident‑to‑resident abuse.
The facility failed to prevent multiple episodes of resident‑to‑resident physical abuse involving cognitively intact and impaired residents with significant psychiatric and behavioral histories. In separate incidents, two residents fought over misdirected clothing, leading one to stab the other with broken scissors; one resident struck another in the eye and banged the resident’s head on the floor, causing a hematoma; a dispute over a small cash debt for shoes escalated when one resident hit another near the ear; a resident who frequently exhibited aggressive behaviors dismantled an air conditioner skirt and another resident slammed this resident to the floor, causing a head injury; and other altercations arose when a resident hit another after a drink was thrown on staff, and when a resident scratched and struck another in a dining area, causing a swollen, lacerated lip and scalp scratches. Staff often heard or observed verbal escalation but did not consistently intervene or separate residents before physical contact occurred, resulting in injuries that in some cases required hospital evaluation.
Two residents with significant psychiatric histories and documented triggers related to theft and personal space became involved in a verbal dispute over a misdirected package containing jeans that one resident had received and attempted to sell. Staff who heard and observed the escalating argument did not immediately activate the facility’s behavioral emergency Code [NAME] as required, and one resident produced a broken pair of scissors kept in his/her room despite policies requiring sharp objects to be secured by staff. The confrontation escalated into a physical fight in which both residents exchanged punches and one resident stabbed the other in the forearm, resulting in a hospital visit for a stab wound repair and concussion. Staff involved had not reviewed the residents’ individualized care plans and ICSPs outlining behavioral triggers and coping strategies, front desk/package-handling procedures were not properly followed, scissors were not retrieved from the resident after use, and the psychiatric NP was not notified of the behavioral incident, all contributing to the failure to provide necessary behavioral health care and services.
The facility failed to follow its abuse and neglect policy requiring written statements from all involved staff and residents during investigations of alleged abuse. In two separate resident-to-resident altercations involving individuals with schizophrenia and schizoaffective disorder, one event resulted in a hematoma and eye redness and the other in a head injury after a resident was taken to the ground. In both cases, the RNI documented the incidents and was signed as complete, but no witness statements were collected, even though a CMT and an LPN who were directly involved reported they were not asked to write statements. The DON and administrators acknowledged that complete investigations should include written statements from all witnesses and capable residents, but the investigations for these incidents consisted only of the RNI forms without the required documentation.
The facility failed to prevent repeated episodes of resident-to-resident physical abuse involving multiple cognitively intact and cognitively impaired residents with significant psychiatric, behavioral, and neurocognitive diagnoses. In separate incidents, residents punched, hit, or pushed one another in halls, rooms, and smoking areas over triggers such as being bumped by a door, being touched on the shoulder, food being taken, urinating on a smoke deck, refusal to share a cigarette, and interpersonal conflicts. These altercations resulted in injuries including a facial laceration requiring sutures, a nasal fracture, a hand laceration from a brick wall, neck discoloration, and reported pain, while witnesses and staff consistently described the conduct as abuse under the facility’s own abuse policy.
A resident with significant psychiatric and behavioral diagnoses engaged in self-injurious behavior with a broken plastic mirror, prompting a behavioral Code response by the DON, an LPN, an RN, and other staff. After the resident dropped the shard and repeatedly requested hospital transfer, the situation escalated when the resident attempted to leave the room and the DON blocked the doorway, told the resident he/she was not going anywhere, and initiated physical contact. Video and multiple witness statements showed the DON pushing the resident into the hallway wall, placing hands and/or forearms on the resident’s shoulder, clavicle, and neck area in a manner inconsistent with CPI techniques and facility policy, which strictly prohibited any neck contact. The facility’s investigation substantiated that the DON used unnecessary physical force and violated the resident’s dignity and rights, while the resident reported being choked, expressed fear and nightmares, and stated not feeling safe. Despite policy requiring immediate removal of staff accused of mistreatment from resident contact, the DON continued working on the unit after the incident.
A resident with complex psychiatric and neurocognitive diagnoses, a history of self‑harm, and a detailed behavioral care plan experienced an escalation after becoming upset while on the smoke deck. Despite care‑plan directives to avoid confrontation, respect personal space, reduce stimulation, and use specific coping skills, the DON engaged in yelling with the resident, blocked the resident’s room doorway, and followed the resident into the hall. Video and witness accounts showed the DON pushed the resident against a wall and placed a hand or forearm near the resident’s neck/clavicle area while attempting a CPI hold that did not follow approved CPI training. Other staff reported CPI verbal de‑escalation and care‑planned coping strategies were not fully used, the DON was a trigger and did not disengage, and the resident later reported being choked and scratched and feeling unsafe. The facility’s investigation found CPI techniques were not correctly implemented, the resident’s behavioral care plan was not followed, and the resident was subjected to unnecessary physical contact and psychosocial distress.
A resident with schizoaffective disorder, PTSD, anxiety, and autism engaged in self‑injurious behavior, prompting a behavioral code response during which the DON physically engaged the resident, including pushing the resident against a wall and placing hands or forearm in the neck/clavicle area while other staff attempted CPI techniques. Staff present, including an LPN, RN, and an assistant administrator, did not immediately report the DON’s actions as suspected abuse to the administrator or state agency, and one nurse later stated fear of retaliation. The administrator initially received only a report of resident self‑harm, learned of the alleged abuse later from an LPN, and completed an internal abuse reporting form days after the event; a subsequent fax of this report to state and federal agencies failed and was not promptly re‑sent. As a result, the suspected employee‑to‑resident abuse with possible injury was not reported to the state survey agency within the required two‑hour timeframe.
Two residents with significant psychiatric histories and documented behavioral risks engaged in escalating verbal and physical altercations after one repeatedly requested money from the other. Following the first incident, staff briefly separated them, but did not escort or supervise the aggressive resident back to another hall or ensure ongoing separation, despite care plan directives to monitor for agitation, divert attention, remove residents from situations, and protect others’ safety. The residents encountered each other again near the nurse’s station, where one punched the other in the face, causing a fall to the floor, and then kicked the resident in the head, resulting in a bloody nose, loss of consciousness, and facial contusions documented at the hospital. This sequence of events, corroborated by resident statements, staff interviews, and progress notes, shows a failure to protect a resident from physical abuse.
Two residents with significant psychiatric histories, including schizophrenia, schizoaffective disorder, PTSD, and prior violence and aggression, engaged in a verbal dispute that escalated into a physical altercation in a hallway, during which one resident punched the other twice before staff separated them. After separation, one resident was allowed to walk unescorted toward a locked unit while the other returned to their room, and no intensive behavioral monitoring or escort was implemented despite facility policies and known behavioral risks. Shortly thereafter, the residents encountered each other again near the nurse’s station, where one resident punched the other in the face, causing a fall, and then kicked the resident in the head, resulting in a bloody nose and loss of consciousness. Staff interviews confirmed that residents from the locked unit typically walked unescorted through another hall, the door between units did not always lock, and no staff had been directed to provide extra monitoring for either resident after the first incident, demonstrating a failure to ensure sufficient and competent behavioral health staffing and monitoring.
A resident with a history of mental health disorders was assaulted while sleeping by another resident, resulting in multiple facial lacerations caused by fingernails and a broken pen. The incident followed a dispute involving accusations of theft and property disruption. Staff responded to the altercation, observed the injuries, and law enforcement was involved, with the aggressor receiving a citation for assault.
A CNA physically abused a resident with severe cognitive impairment and behavioral health diagnoses during a behavioral incident, resulting in a nasal bone fracture and other injuries. The CNA struck the resident multiple times after being hit by the resident, and staff had to intervene to separate them. The incident was witnessed by multiple staff and another resident, and was reported as abuse and assault, with medical evaluation confirming significant injuries.
The facility did not ensure all staff received required behavioral health and CPI training, resulting in several employees, including a CNA, working without proper preparation. This led to an incident where a CNA without documented training physically struck a resident with psychiatric diagnoses during a behavioral crisis, causing injury. Staff interviews and record reviews confirmed gaps in training and documentation, and the facility lacked an effective system to track staff training compliance.
A resident with a gastrostomy tube and multiple medical conditions was served lumpy oatmeal instead of the physician-ordered pureed diet with nectar-thick liquids. Staff interviews revealed confusion about proper pureed food preparation, and the cook admitted to not pureeing the oatmeal due to time constraints. Facility policy required pureed foods to have a smooth, pudding-like consistency, but this was not followed, and there was no documentation supporting any change in the resident's diet.
A staff member failed to maintain professional boundaries by hugging and kissing two residents, making one feel uncomfortable, and by taking a resident's spending card off the premises. Both residents had significant mental health diagnoses and required protective oversight. Multiple staff and video surveillance confirmed the inappropriate conduct, which violated facility policies on dignity, respect, and resident rights.
A resident with a history of psychiatric and behavioral issues physically assaulted another resident after a refused sexual advance, resulting in the loss of two front teeth. The incident was not reported by either resident at the time, and staff only discovered the injury the following morning during routine observation.
The facility did not maintain a full-time qualified LSW as required, resulting in missed social services documentation, assessments, and care planning for residents with complex mental health and psychosocial needs. Multiple residents went without necessary social work interventions, and required discharge logs were not submitted to the Ombudsman, as confirmed by staff and external interviews.
The facility did not provide access to condoms or private spaces for sexually active residents, despite several cognitively intact residents expressing interest in safe sexual activity and recalling that such resources were previously available. Leadership acknowledged that these measures were not implemented due to a perceived lack of resident interest, resulting in a failure to support residents' rights to privacy and safe sexual expression.
A resident with multiple mental health diagnoses and a low level of personal hygiene was left without access to clean clothing, resulting in wearing the same soiled clothes for two days. Observations and interviews confirmed the absence of clothing in the resident's room, and staff did not consistently follow procedures to provide replacement clothing. The deficiency reflects a failure to support resident choice and dignity as outlined in facility policy.
A resident with mild cognitive impairment was denied visitation by their friend and family member after the DON refused access to the unit and did not facilitate an alternative meeting location. Multiple staff and the resident's guardian reported no negative interactions with the visitors, and the facility lacked a written visitor policy, resulting in a failure to uphold the resident's rights.
Multiple rooms on a gender-specific unit were found with unsanitary conditions, including clogged sinks with standing dirty water, soiled bathrooms, and inadequate hot water temperatures below 105°F. A resident and others reported these issues to staff, but no timely action was taken. Staff interviews revealed inconsistent housekeeping due to staffing shortages and a recent transition in cleaning services, resulting in direct care staff being expected to perform cleaning duties in addition to their primary roles.
The facility failed to reassess and coordinate the return or alternative placement of three residents who were transferred to the hospital and later found to be medically stable and no longer a safety risk. Despite providing immediate discharge notices and required information to guardians and the ombudsman, the facility did not communicate or collaborate with hospital staff or guardians to facilitate the residents' return or alternative placement, and did not reassess the residents' needs after hospitalization.
Multiple resident rooms experienced ongoing issues with clogged sinks and discolored standing water, with some sinks and toilets remaining unusable for several days. Affected residents, including those with mental health conditions, reported the problems to staff, but maintenance response was delayed due to inadequate communication and staffing. Staff interviews confirmed that improper items were being placed in sinks and toilets, and that the facility's system for reporting and addressing maintenance concerns was ineffective.
Two residents were not protected from abuse, resulting in one being sexually abused multiple times by a cognitively impaired roommate with a history of sex offenses, and another suffering a physical injury requiring sutures after being struck by a cup thrown by a roommate with behavioral health issues. Staff failed to act promptly on reports of abuse, did not separate the residents involved, and did not follow facility policy for immediate intervention.
A CMT responded to a resident with dementia and traumatic brain injury by using foul language after the resident made an unintelligible or possibly inappropriate comment. The incident, witnessed by the Administrator and another CMT, violated facility policies and the resident's care plan, which required staff to maintain professionalism and treat residents with dignity and respect.
A resident with a history of depression and stroke, who was cognitively intact, reported being sexually abused by another resident during the night. The CNA informed the LPN, but the LPN did not escalate the report to administrative staff as required by policy. The incident was not addressed until the DON learned of it during morning rounds, resulting in a delay in reporting the allegation of abuse.
Multiple residents experienced physical abuse, including being pushed, held, bitten, and struck, due to staff and peer altercations. Staff failed to intervene or provide required supervision, and care plans for behavioral management and safety were not followed, resulting in injuries and fear among residents.
The facility did not thoroughly investigate multiple abuse allegations, including incidents involving two residents with psychiatric conditions and legal guardians who engaged in sexual activity without complete capacity to consent assessments, and another resident who alleged being struck by a CNA. Required witness interviews, documentation, and assessments were incomplete or missing, and the facility did not follow its own policies for abuse investigations.
A resident with complex behavioral health diagnoses and a history of self-harm and aggression was not provided with the required continuous 1-1 supervision as outlined in their care plan and facility policy. Staff were often not within eyesight or arms reach, failed to document supervision, and sometimes performed other duties while assigned to 1-1. This lack of supervision led to the resident being assaulted by another resident and sustaining a head injury, as well as additional self-harm incidents when left unsupervised.
Facility staff did not notify the legal guardian when a resident with multiple psychiatric and medical conditions was transferred to the hospital after calling 911. Despite facility policy requiring notification of guardians for significant changes in condition or transfers, staff interviews and documentation confirmed that the guardian was not informed.
A resident with a history of psychiatric and neurocognitive disorders became agitated after their room was cleaned and laundry removed, leading to a physical altercation with an LPN. During the incident, the resident was held on the floor by both staff and another resident, contrary to facility policy and CPI training, which prohibit floor holds and resident involvement in restraints. Staff did not redirect other residents away from the situation, and the required de-escalation strategies in the resident's care plan were not followed.
The facility did not notify physicians or resident representatives when three residents, including those with severe cognitive impairment and complex psychiatric diagnoses, missed multiple prescribed medications due to unavailability. Despite facility policy requiring such notifications, documentation and staff interviews confirmed that neither clinicians nor guardians were informed, and the administrator and nurse practitioner were unaware of the missed doses.
Multiple residents with significant psychiatric and behavioral histories engaged in physical altercations, resulting in injuries and hospital evaluations. Staff and administration confirmed these incidents met the definition of abuse according to policy and state statute, indicating a failure to prevent resident-to-resident abuse despite known risks.
Three residents with severe mental health and behavioral diagnoses did not receive prescribed medications for extended periods, resulting in sexually charged behaviors between two residents in a community shower and an altercation involving another resident. Staff and resident interviews confirmed that medication lapses contributed to these incidents, and facility policies requiring medication administration and monitoring were not followed.
Three residents with chronic mental health and medical conditions did not receive their prescribed medications for several days, including antipsychotics, mood stabilizers, and seizure medications. Staff interviews and records showed that medication lapses were due to pharmacy delivery issues, incomplete prior authorizations, and lack of communication, with no documentation that physicians or guardians were notified. These omissions led to increased behavioral incidents and, in one case, seizure activity.
Two medication carts were left unlocked and unattended, allowing four residents with histories of substance abuse and psychiatric disorders to access and obtain medications, including controlled substances such as Oxycodone. Staff failed to maintain direct supervision and did not secure the carts or keys as required, resulting in unauthorized removal and ingestion of medications.
A facility failed to provide appropriate behavioral health care and supervision for a resident with PTSD and self-harming behaviors. The resident was inconsistently supervised, leading to self-harm incidents. The facility did not involve the IDT in decision-making, and the resident's care plan was not consistently followed, contributing to the resident's continued self-harming behaviors.
Two residents with significant behavioral and psychiatric histories were physically abused by staff members, including a CNA and a hall monitor, who engaged in altercations resulting in injuries to one resident. Other staff present failed to intervene appropriately, and video evidence confirmed that staff used physical force instead of de-escalation techniques, despite having received training on abuse prevention.
A resident with a history of psychiatric illness and self-harm was able to obtain and conceal a disposable razor, later using it to inflict a superficial cut on their forearm. Despite a facility protocol requiring razors to be checked out by a charge nurse, supervised use, and immediate return for disposal, staff did not observe the resident shaving or ensure the razor was returned. The incident revealed a lapse in following safety protocols for sharps management and resident supervision.
A resident with dementia frequently wandered into other residents' rooms, causing distress and safety concerns. Despite being identified as at risk for wandering, the care plan lacked specific interventions, and staff were not adequately trained to manage the situation. This led to incidents of physical aggression and highlighted a deficiency in the facility's dementia care practices.
A resident with COPD and other conditions reported feeling belittled by a CNA who was rough and rude during care. Audio recordings revealed the CNA's gruff manner and dismissive attitude towards the resident's discomfort. The facility's Administrator acknowledged the CNA's inappropriate behavior, highlighting a deficiency in maintaining resident dignity and respect.
A resident with schizophrenia was sent to the hospital due to aggressive behavior and a swollen arm. The facility failed to notify the resident's guardian about the hospitalization, the abscess treatment, and the new antibiotic prescription, despite policy requirements. The LPN left a voicemail but did not confirm receipt, and the guardian reported not being informed or receiving requested documentation.
A resident with a history of elopement and significant mental illness left the facility without guardian consent. The receptionist allowed the resident to leave with someone they claimed was their spouse, without verifying permissions or completing the required outside pass form. The facility failed to conduct necessary elopement assessments and did not follow established protocols for resident departures.
A resident in a LTC facility was assaulted by another resident, resulting in a broken nose. The incident was unwitnessed, and both residents involved had complex mental health histories. The facility's investigation concluded that the injury was not preventable, and no prior interaction or triggers were observed between the residents on the day of the incident.
The facility failed to maintain a comfortable environment as room temperatures exceeded the recommended range, affecting multiple residents. Despite having an Emergency Operations Plan for HVAC failures, the facility did not adhere to it, resulting in discomfort and distress for residents. Interviews revealed that staff were aware of the issues but did not take adequate action to resolve them.
A resident with a history of mental disorders, including PTSD, was involved in a physical altercation with an LPN after becoming frustrated over a missing check. The resident's care plan, which included de-escalation strategies and awareness of triggers, was not followed. The LPN engaged physically with the resident, leading to the resident falling, although no injury was found. The Director of Nursing confirmed that the LPN should have de-escalated the situation.
A resident with schizophrenia and other mental disorders was involved in an incident where the Administrator failed to maintain their dignity by engaging in a playful manner during an escalated situation. The Administrator lightly pushed the resident on the back, leading to the resident attempting to strike the Administrator. The investigation found no abuse but noted the Administrator's inappropriate handling of the situation.
Two residents experienced discomfort due to the facility's failure to maintain room temperatures between 71 and 81 degrees Fahrenheit. Despite complaints from a resident with significant health issues, the air conditioning unit was not promptly repaired, and alternative cooling measures were inadequate. Staff adjustments to the unit were insufficient, and follow-up temperature checks were not conducted.
A resident with a complex mental health history was physically abused by a CNA over a dispute involving a bag of chips. The CNA forcibly pushed the resident down a hallway, an action witnessed by other staff who did not intervene. The incident highlighted a failure to use de-escalation techniques and adhere to the facility's abuse policy.
Facility staff failed to report an abuse incident involving a resident and a CNA to the Administrator as required by policy. The incident involved a physical altercation over a bag of chips, where a CNA shoved and pushed a resident with multiple psychiatric disorders. Despite witnessing the event, other staff did not report it immediately, leading to a delay in investigation.
Failure to Prevent Multiple Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse in multiple resident‑to‑resident altercations, despite having an Abuse and Neglect Policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy specifies that physical abuse includes hitting, slapping, punching, biting, and kicking, and applies to all residents regardless of mental or physical condition. In several incidents, residents with known psychiatric and behavioral histories engaged in physical aggression toward peers, resulting in injuries such as head swelling, knuckle injury, and a facial laceration. In the first series of events, one resident with bipolar disorder, intermittent explosive disorder, ADHD, intellectual disability, major depressive disorder, anxiety disorder, and a history of angry outbursts and poor judgment (assessed as cognitively intact on the MDS) was on 1:1 observation with a CNA when he/she became verbally involved with another resident in the main front hall. This second resident had bipolar disorder, ADHD, bipolar II disorder, chronic PTSD, generalized anxiety disorder, autistic disorder, and a PASRR noting behavioral difficulty, anger control issues, boundary problems, and impaired judgment, and was also assessed as cognitively intact. During a verbal altercation about another resident, the 1:1 CNA attempted to redirect the first resident and instructed him/her to walk away. As the resident began to walk away, he/she stated an intention to kick the other resident in the face and then kicked the peer in the leg. The second resident responded by striking the first resident on the right side of the head multiple times, causing several lumps and swelling, while sustaining injury to his/her own right hand/knuckles. Staff called a behavioral emergency code and separated the residents after the physical fight had already occurred. In a separate incident, the same second resident, who had a documented history of behavioral escalation, fixation, and difficulty with redirection, left his/her assigned unit against direction during a period of ongoing behavioral concerns. While upset about not having access to a hangout area and distressed about another resident’s family not wanting him/her around, this resident directed aggression toward another peer who was walking by and kicked that resident in the shin. The targeted resident, who was cognitively impaired and generally kept to him/herself, reported remembering being kicked, feeling upset, but not retaliating; no physical injury was documented. Facility documentation characterized this as a resident‑to‑resident altercation initiated by the aggressive resident after several days of escalating behaviors. Another altercation involved two cognitively intact residents with psychiatric diagnoses, including traumatic brain injury and paranoid schizophrenia for one resident, and mild cognitive impairment, paranoid schizophrenia, and anxiety disorder for the other. Multiple CNAs reported that the two residents bumped into each other in a hallway, exchanged words, and then “squared up” with raised fists. One resident hit the other above the eye, with some accounts indicating two punches to the face, causing the struck resident to hit his/her head on the wall and fall to the floor. The injured resident was later observed with two scratches above the left eyebrow, which staff cleaned and covered with a bandage. The aggressor resident admitted he/she hit the other resident on purpose and was trying to hurt him/her. Staff were present in nearby halls and ran over when they heard yelling, but the physical blows occurred before they could stop the assault. Across these events, the facility’s own investigation documents describe the altercations as substantiated resident‑to‑resident physical aggression, initiated by residents who kicked or struck peers intentionally and not accidentally. The Psychiatric NP acknowledged that kicking someone for no reason constitutes abuse and noted that residents involved had impulsive behaviors and difficulty reasoning about consequences. The DON and Administrator described the residents as impulsive and overstimulated, with actions they considered not predictable, while also confirming the sequence of verbal escalation, threats, and subsequent physical aggression in the incidents. These documented episodes of willful physical contact—kicking and punching—between residents, resulting in injuries and occurring despite staff presence and prior knowledge of behavioral histories, constitute the failure to prevent physical abuse as required by the facility’s abuse policy.
Failure to Prevent Repeated Resident‑to‑Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known psychiatric and behavioral histories. One incident occurred when a cognitively intact resident with schizophrenia and a history of aggressive behavior was mistakenly given another resident’s jeans. After the resident attempted to sell the jeans, the rightful owner, who also had multiple serious psychiatric diagnoses and a history of psychosis and combative behavior, confronted the resident. Staff observed the verbal escalation during shift change but did not separate the residents before the argument became physical. The confrontation escalated into both residents punching each other, and one resident produced broken scissors and stabbed the other in the forearm, resulting in a stab wound requiring staples and hospital treatment. Another incident involved a cognitively intact resident with schizophrenia and documented physical behaviors toward others one to three days per week. This resident engaged in a physical altercation with another cognitively intact resident diagnosed with schizoaffective and antisocial personality disorders. Staff and documentation indicated that one resident struck the other in the eye, causing a fall against a wall, followed by the aggressor banging the victim’s head on the floor. The victim developed a visible hematoma above the right eye with redness and irritation. Although EMS was activated, the injured resident repeatedly refused treatment and nursing assessments. The facility’s investigation substantiated this as abuse, citing exposure to an aggressive resident and the resulting head injury. Additional resident‑to‑resident altercations occurred in various contexts, including disputes over money and personal items, and reactions to other residents’ behaviors. In one case, a cognitively intact resident with multiple psychiatric diagnoses struck another cognitively intact resident with schizophrenia and TBI during a banking/activity interaction after a verbal disagreement about a $5 debt for shoes, causing an abrasion behind the ear. In another event, a resident with paranoid schizophrenia who exhibited daily physical and verbal behaviors dismantled an air conditioner skirt and swung it toward staff; another cognitively intact resident with schizophrenia and schizoaffective disorder then grabbed this resident and slammed them to the floor, causing a head injury that required hospital evaluation. Other incidents included a cognitively intact resident hitting another resident after a verbal altercation involving thrown ice and chairs, and a resident with schizoaffective disorder striking and scratching a cognitively intact resident with multiple psychiatric diagnoses in the dining area, resulting in a swollen, lacerated lip, scalp scratches, and reported fear of the aggressor. Across these events, staff either arrived after physical contact had already occurred or did not intervene in time to prevent physical abuse between residents. The facility’s own records and interviews show that staff were aware of residents’ significant psychiatric histories, behavioral patterns, and prior aggression, yet resident‑to‑resident altercations repeatedly escalated to physical abuse causing injuries such as stab wounds, hematomas, abrasions, and lacerations. In several cases, staff heard arguments or saw verbal escalation but did not promptly separate residents or call the facility’s behavioral emergency code before physical violence occurred. The Administrator acknowledged that once staff hear raised voices, they should move toward the source and determine if residents are escalating and, if so, call a Code immediately. The pattern of incidents from multiple dates, involving different residents and locations within the facility, demonstrates a failure to consistently implement the facility’s abuse and neglect policy to prevent physical abuse between residents. The survey identified these failures as an Immediate Jeopardy situation beginning on 3/23/26, based on the repeated resident‑to‑resident physical abuse incidents and the facility’s inability to prevent them. The facility’s own investigations repeatedly substantiated these events as abuse, noting preventable circumstances such as mishandled property, failure to remove escalating residents from shared areas, and delayed staff intervention despite observable verbal conflicts. The deficiency was ultimately cited at a lowered severity level after onsite verification that corrective actions had been implemented, but the documented events themselves reflect the underlying failure to protect residents from physical abuse by other residents during the period reviewed.
Failure to Implement Behavioral Health and Safety Protocols During Resident Altercation Over Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to implement its behavioral health practices and procedures when two residents with significant psychiatric histories escalated from a verbal dispute into a physical altercation resulting in injury. One resident had a PASRR diagnosis of schizophrenia with a history of difficulty getting along with others, frequent altercations, evictions, fear of strangers, and failed placements in less restrictive environments due to aggressive behaviors. The other resident had PASRR diagnoses including schizoaffective disorder bipolar type, Bipolar I Disorder, Major Depressive Disorder, psychosis, schizophrenia, and epilepsy with potential cognitive impairments such as memory loss, slow processing, and poor safety awareness. Both residents’ care plans and ICSPs identified triggers related to theft or loss of belongings, people getting into their personal space, and being bullied, and listed individualized coping strategies such as drawing/painting, going outside, smoking, having coffee or soda, and watching TV. The sequence of events began when an activity aide, who reported never being educated on how to receive and distribute packages, gave a package to one resident after confirming the name on the package, not realizing that the resident’s first name matched another resident’s last name. The package actually contained jeans intended for the other resident. The resident who received the package later realized the jeans were not his/hers and decided to sell them to another resident. The intended recipient discovered the jeans were missing and confronted the resident who had received and attempted to sell them. Staff, including a CNA and a CMT, reported that they heard or observed a verbal argument between the two residents about the pants and that residents in the facility often became upset when others borrowed, stole, or sold their belongings, with such issues frequently leading to fights. Despite facility expectations and staff education that a behavioral emergency Code [NAME] should be called as soon as a verbal altercation or escalation was observed, staff did not initiate the code at the onset of the argument. CMT A acknowledged responding to the verbal altercation but did not call the code until seeing scissors in one resident’s hand, and CNA A stated he/she heard yelling, went to the residents, and tried to break up the fight without calling a code when the situation was still verbal. During the altercation, both residents exchanged punches, and one resident produced a broken pair of scissors and stabbed the other in the left forearm. Staff then intervened using CPI techniques, separated the residents, and removed the scissors. The injured resident was transported to the hospital, where records documented a stab wound to the underside of the left forearm that required repair and staples, and a concussion with a neck brace. The facility’s own investigation substantiated that resident property was mishandled, staff identified the argument but did not intervene soon enough to separate the residents, and the delay in calling Code [NAME] and failure to promptly remove scissors from the resident contributed to the physical altercation and resulting injury. Additional deficiencies in behavioral health coordination and safety procedures were identified. The facility’s behavioral health policy required close monitoring for distress, documentation of behavioral changes and triggers, and multidisciplinary team involvement, including psychiatric input, when behaviors occurred. However, review of the injured resident’s medical record showed no documentation that the psychiatric nurse practitioner was notified of the resident-to-resident altercation, despite the PNP’s expectation to be informed of every incident and behavior to provide appropriate recommendations. The facility’s policy on screens/searches upon entering the facility required all sharp objects to be secured by staff and not kept with residents, yet one resident reported keeping scissors locked in a drawer in his/her room and using them for art, and the DON and administrator both stated that staff should always retrieve scissors from the resident after use and that the resident should never have kept scissors in the room. Staff also reported that they had not reviewed the residents’ ICSPs and were not familiar with their specific triggers and interventions, even though the ICSPs contained detailed behavioral triggers and coping strategies intended to guide staff responses. These combined failures to follow behavioral health policies, emergency response procedures, contraband/sharp object controls, and psychiatric notification requirements led to the escalation of a known trigger situation into a serious resident-to-resident physical altercation with injury. The facility’s own Registered Nurse Investigation documented that the incident was substantiated as physical aggression not involving the head, arising from mishandling of resident property and delayed staff intervention. Staff statements and interviews with the DON, administrator, and PNP confirmed that the Code [NAME] was not called at the first sign of verbal escalation, that staff did not consistently remove scissors from the resident after use, that front desk/package-handling staff were not fully educated on package protocols, and that the PNP was not notified of the behavioral incident. Observations of the injured resident after return from the hospital showed a healing wound on the left forearm with staples removed and surrounding redness. These facts collectively demonstrate that the facility did not ensure residents received necessary behavioral health care and services in accordance with its own policies, did not adequately implement crisis prevention and intervention practices, and did not maintain environmental and procedural controls (including contraband/sharp object management and package handling) necessary to support residents’ mental and psychosocial well-being and safety. The deficiency is further supported by staff acknowledgments that resident-to-resident altercations frequently occur over borrowing, stealing, or selling items, and that many residents are triggered when their belongings are taken or tampered with. Despite this known pattern and the specific triggers documented in both residents’ care plans and ICSPs, staff involved in the incident had not reviewed those plans and were unaware of the residents’ individualized triggers and de-escalation strategies. The facility’s behavioral health policy required staff to monitor for distress, evaluate behavioral changes, and develop person-centered care based on identified concerns, but in this case, staff did not use the available information on triggers and coping skills to intervene early or redirect the residents before the situation escalated. The lack of timely behavioral emergency activation, failure to secure sharp objects, improper handling of resident property, and absence of psychiatric notification after a significant behavioral event collectively demonstrate a failure to provide necessary behavioral health care and services as required by the facility’s own policies and procedures.
Failure to Obtain Required Witness Statements in Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse and Neglect policy requiring collection of personal statements from staff and residents involved in any situation with an accusation of abuse, including resident-to-resident abuse. The policy, revised 6/12/24, directed the Administrator or designee to complete an administrative investigation that included written statements from all involved parties. For multiple resident-to-resident physical altercations, the facility’s investigations, documented on Registered Nurse Investigation (RNI) forms, did not include any witness statements, despite staff and leadership acknowledging that such statements were expected and normally obtained. In one incident, two residents with serious mental health diagnoses (schizophrenia and schizoaffective disorder) were involved in a physical altercation. Nursing progress notes documented that one resident struck the other multiple times, causing a fall and head impact against a wall, after which the other resident banged the fallen resident’s head on the floor. One resident had no apparent injuries, while the other had a hematoma above the right eye with surrounding redness and a reddened right eye. The RNI described the event, the calling of a behavioral emergency code, and staff intervention to separate and secure the residents, and bore the Administrator’s signature as completed; however, no witness statements were attached. Interviews with a certified medication technician and an LPN confirmed they were present and typically would have been asked to write statements, but were not asked and did not provide any for this incident. In a separate incident, two other residents with diagnoses including paranoid schizophrenia, schizophrenia, and schizoaffective disorder were involved in an altercation after one resident became agitated outside. As staff attempted to lead this resident back inside, the resident dismantled part of an air conditioner unit skirt and swung it toward staff. Another resident intervened by grabbing the agitated resident and taking the resident to the ground, resulting in a head injury from hitting the floor. The RNI documented the sequence of events and identified the incident as physical aggression involving the head, but again contained no witness statements. An LPN who was the primary staff member involved reported not being asked to write a statement, despite usually doing so for such events. The DON and both Administrators acknowledged that a complete investigation should include written statements from all staff and capable residents involved, and that the DON was typically methodical in collecting and organizing these, but in these cases the investigations were limited to the RNI forms without the required statements.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known behavioral histories and triggers. The facility’s own Abuse and Neglect Policy defines abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and includes hitting, slapping, punching, biting, and kicking. Across several incidents, residents with significant psychiatric and neurocognitive diagnoses engaged in physical altercations that resulted in injuries such as a lacerated lip requiring sutures, nasal fracture, and hand laceration. These events occurred in common areas such as smoke decks, patios, and halls, often in the presence of other residents and sometimes without staff immediately present. One incident involved a cognitively intact resident with paranoid schizophrenia and a history of hitting behaviors, whose care plan identified triggers such as when someone was “mouthing off” and noted unused coping skills. This resident and another cognitively intact resident with schizophrenia and a history of agitation and threatening behavior had a physical altercation after a bump with a door, resulting in a facial laceration and lip injury requiring sutures. In another event, a resident with traumatic brain injury and moderate cognitive impairment placed a hand on the shoulder of a cognitively intact resident with multiple serious psychiatric diagnoses, who responded by punching the first resident in the chest. Witness accounts confirmed that the contact to the shoulder was not forceful, but the response was a hard punch that caused pain and sadness to the victim. Additional altercations occurred between residents with complex psychiatric and behavioral profiles. One cognitively intact resident with schizoaffective and personality disorders entered another cognitively intact resident’s room and ate that resident’s food, leading to a fight in which both hit each other and one sustained a nasal fracture. Another cognitively intact resident pushed a cognitively impaired peer who was urinating on a smoke deck, after verbally telling the peer to stop; the pushed resident slipped in urine and scraped a hand on a brick wall, causing a laceration. On a smoking patio, a cognitively intact resident with bipolar disorder and intermittent explosive disorder refused to share a cigarette with another cognitively intact resident with schizophrenia and psychosis; the latter admitted to hitting the former multiple times in the head and face with a fist, causing the resident to fall to the ground. Further, a cognitively intact resident with bipolar disorder, ADHD, intellectual disability, and a history of angry outbursts was involved in a separate altercation with another cognitively intact resident with bipolar disorder, PTSD, autism, and anger control issues. Conflicting statements indicated that one resident had been “messing with” or bullying the other and that both admitted to hitting each other, with witnesses describing one resident running toward the other and initiating contact, leading both to fall to the ground. Discoloration was noted on one resident’s neck, and another resident reported temple pain. Throughout these events, staff and resident interviews, written statements, and facility documentation consistently characterized the physical acts—punching, hitting, and pushing—as abuse, and leadership acknowledged that residents “could not go around hitting each other,” yet multiple episodes of resident-to-resident physical aggression occurred involving nine sampled residents.
Abusive Physical Intervention by DON and Failure to Remove Accused Staff from Resident Contact
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to follow its own abuse and CPI (Crisis Prevention Intervention) policies during a behavioral incident. A cognitively intact resident with multiple psychiatric diagnoses, including Schizoaffective Disorder, Bipolar I Disorder, PTSD, Autism Spectrum Disorder, and a history of self-harm and violent temper, became upset and engaged in self-injurious behavior using a broken plastic mirror. A Code for behavioral crisis was called, and the DON, an LPN, an RN, and other staff responded. In the resident’s room, the resident held a shard of the broken mirror, threatened to harm staff if they came closer, and attempted to cut his/her left forearm. Staff, including the DON and LPN, attempted verbal de-escalation and CPI techniques, and the resident eventually dropped the shard and sat down, repeatedly asking to be sent to the hospital. The situation escalated again when the resident attempted to leave the room. Multiple witness statements and video footage show that the DON blocked the doorway with his/her body and told the resident he/she was not going anywhere, contrary to facility policy that staff should never attempt to confine a resident to a room during a behavioral episode and should use the least restrictive interventions. As the resident tried to get past, the DON initiated physical contact, placing hands and/or forearms on the resident’s shoulder, collarbone, and neck area while the resident backed into the hallway and against the wall. The video showed the DON extending both arms toward the resident’s neck/clavicle/shoulder area, lifting a foot to block the resident’s movement, and pushing the resident’s back against the wall while holding the resident there. Witnesses, including the LPN and AA, reported that the DON’s hands appeared to move from the shoulders up to the neck, and the AA was heard repeatedly yelling for the DON to keep hands on the resident’s shoulders. The facility’s internal investigation, supported by witness accounts, video footage, and the resident’s own statements, determined that the DON initiated inappropriate physical contact, used unnecessary physical force, and placed a hand around the resident’s neck area during the attempted hold. This contact around the neck was not consistent with approved CPI techniques, was strictly prohibited by facility policy, and represented a misuse of authority and a violation of the resident’s dignity and rights. The investigation concluded that CPI techniques were not correctly utilized, that alternative de-escalation methods were not fully employed before physical intervention, and that the DON’s actions further stimulated and escalated the resident’s behavior. The resident reported being choked by the DON, expressed fear, nightmares, and flashbacks of the DON coming back to strangle him/her, and stated he/she did not feel safe living at the facility. Despite the incident occurring at approximately 7:40 p.m., the DON continued to work the shift until 9:45 p.m., and the employee was not immediately removed from the facility or from resident contact as required by the facility’s Abuse and Neglect Policy. The facility’s Abuse and Neglect Policy required that employees accused of mistreatment be immediately removed from contact with residents and leave the facility pending investigation, and specifically prohibited any form of contact involving a resident’s neck. The policy also required that, if the alleged abuser was the Administrator or DON, they could remain only in non-resident areas with no resident contact. In this case, the DON remained on duty and in the facility after the incident and was not removed from resident contact during the time period described. The combination of the DON’s physical actions toward the resident, the improper and non-approved CPI techniques used, the blocking of the resident’s exit, and the failure to remove the accused staff member from resident contact constituted the abuse-related deficiency identified by surveyors.
Failure to Implement Behavioral Care Plan and CPI Techniques During Resident Crisis
Penalty
Summary
Facility staff failed to provide necessary behavioral health services and to implement the person‑centered behavioral care plan and CPI de‑escalation techniques for one resident with complex psychiatric and neurocognitive diagnoses. The resident had schizoaffective disorder bipolar type, Bipolar I disorder, DMDD, ODD, borderline personality disorder, PTSD, autism spectrum disorder, traumatic brain injury, and an unspecified neurocognitive disorder related to self‑harm brain injury. The PASRR and care plan documented high‑risk behaviors, history of violent temper, multiple psychiatric admissions, suicide attempts, self‑injurious head‑banging, and the need for a safe, secure setting. The care plan directed staff to ensure a safe environment, avoid confrontation and power struggles, be mindful of personal space, closely monitor for agitation, decrease stimulation, and use specific coping skills such as music with headphones, computer use, reading, writing, and diamond art, as well as weekly meetings with the Administrator as desired. On the evening of 03/06/26, a behavioral incident began on the smoke deck where the resident and the DON were yelling at each other, with the resident upset about limits on calling a parent/guardian. The resident, who was on one‑to‑one monitoring for safety, became increasingly agitated, broke a plexiglass mirror, and obtained sharp plastic pieces. Staff called a behavioral Code. According to staff interviews, LPN A was able to get several pieces of plastic away from the resident and was talking with the resident when the DON entered the room. The resident picked up another sharp piece, threatened self‑harm, and also threatened to stab the DON if approached. Witnesses reported the DON picked up a jagged piece of plastic and made antagonistic statements, and the DON did not remove themself despite being identified as a trigger for the resident. The DON blocked the resident’s doorway with their body, preventing the resident from leaving, contrary to the care plan direction to avoid confrontation and be mindful of personal space. Video footage and multiple witness statements showed that when the resident exited the room and backed down the hallway, the DON followed closely, continued to engage, and initiated physical contact rather than fully utilizing verbal CPI de‑escalation and the resident’s coping strategies. The DON extended arms toward the resident’s clavicle/neck area, pushed the resident against the wall, and attempted a physical hold. The facility’s internal investigation and witnesses, including RN A and LPN A, described the DON’s hand or forearm placement near the resident’s neck or collarbone, with the resident yelling that the DON was choking them. The investigation concluded CPI techniques were not correctly or fully used, that contact with the resident’s neck area occurred despite this being strictly prohibited, and that the DON blocked the resident in the room, followed the resident into the hall, yelled, entered the resident’s personal space, and failed to use the resident’s identified coping skills or person‑centered interventions. The resident was later observed with a 9‑cm red scratch from below the jawline to above the collarbone and reported being choked and scratched by the DON, feeling unsafe, and having nightmares about being strangled by staff. Psychiatric NPs and the Corporate Director of Behavioral Health Services stated staff did not follow CPI principles, did not consistently use the resident’s coping skills or care plan, and that the DON should have disengaged once other staff were present, but instead escalated the situation, resulting in unnecessary physical contact and psychosocial distress for the resident.
Failure to Timely Report Suspected Employee‑to‑Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an employee‑to‑resident altercation with injuries and possible abuse to the state survey agency within the required time frame. The facility’s Abuse and Neglect Policy requires that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property be reported immediately to the Administrator and to appropriate agencies within prescribed state and federal time frames, including within two hours in cases of serious bodily injury. Despite this policy, an incident involving physical contact between the DON and a resident on the evening of 03/06/26 was not reported to the state agency within two hours of occurrence or discovery. The resident involved had diagnoses including schizoaffective disorder, bipolar type, PTSD, anxiety, and autistic disorder, and was assessed as cognitively intact on a recent MDS. Video footage from the date of the incident showed the DON and other nursing staff responding to a behavioral code near the resident’s room. The footage documented the DON extending both arms toward the resident’s neck/clavicle area, placing a hand or forearm against the resident’s clavicle/neck, raising and extending both arms toward the resident’s upper body while the resident attempted to block, and positioning a foot between the resident’s legs while the resident was pushed against the wall. The DON was also seen pushing the resident’s back against the wall and holding the resident there, while other staff, including an LPN, RN, and the Assistant Administrator, were present and at times attempted to separate the DON from the resident. Staff interviews indicated that at least one nurse believed the incident was not appropriate and that the DON did not follow CPI training. Following the incident, documentation in the medical record and initial internal reporting focused on the resident’s self‑injurious behavior and the use of CPI techniques, and did not immediately characterize the DON’s actions as potential abuse. The Assistant Administrator reported to the Administrator that the resident had engaged in self‑harm but did not report that the DON had put hands on the resident’s neck or failed to follow CPI techniques. The LPN and RN who witnessed the event did not directly report suspected abuse to the Administrator or external agencies at the time, relying instead on the Assistant Administrator to contact the Administrator, and one staff member expressed fear of retaliation due to the DON and Assistant Administrator being superiors. The Administrator later learned of the alleged abuse from the LPN on a subsequent date and then initiated the facility’s Initial Reporting Form, which was dated 03/08/26, indicating physical abuse as the allegation type. This sequence of events resulted in the allegation of employee‑to‑resident abuse with injury and possible serious bodily harm not being reported to the state survey agency immediately, and not within the required two‑hour timeframe after the incident occurred or was discovered. Additional delay occurred when the Initial Reporting Form, once prepared, was not successfully transmitted to the state and federal agencies on the first attempt. The Administrator provided the report to the receptionist to fax on the morning of 03/09/26. The receptionist sent the fax but did not verify successful transmission at that time and only checked the transmission report when the Administrator later requested proof of faxing, at which point the transmission was shown as failed. The receptionist did not refax the report after seeing the failure because the Administrator requested the report back. These actions and inactions by multiple staff members, from the time of the incident through the failed fax transmission, contributed to the facility’s failure to ensure that the suspected abuse incident was reported to the state survey agency within the required regulatory timeframe.
Failure to Maintain Separation After Initial Altercation Leads to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse during two altercations between two residents on the same evening. One resident with schizophrenia, delusional disorder, and a history of physical aggression per PASRR approached another resident with schizoaffective disorder bipolar type, PTSD, anxiety, OCD, and schizophrenia, repeatedly asking for money. Both residents had care plans that identified behavioral and crisis-intervention needs, including poor impulse control and a history of violence, impulsivity, and lack of judgment, as well as instructions for staff to monitor for agitation, avoid arguing, divert attention, remove residents from situations, and intervene to protect the rights and safety of others. Despite these identified risks and interventions, the residents engaged in a verbal confrontation in the front hall outside one resident’s room, which escalated into physical violence when one resident punched the other in the head twice. Staff intervened and separated the residents after the first incident. One resident went into his/her room with the door shut, and the other resident walked toward his/her room on a different hall. However, no staff were assigned to escort or supervise the resident returning to the back hall, and staff did not ensure that the two residents remained separated. Shortly thereafter, the resident who had returned to his/her room came back out, went looking for the other resident, and encountered him/her again near the nurse’s station. At this point, the second altercation occurred. Witness accounts and progress notes state that the aggressive resident punched the other resident in the face twice, causing him/her to fall face down to the floor, and then kicked the resident in the head twice. As a result of the second altercation, the injured resident experienced a bloody nose, loss of consciousness, confusion upon regaining consciousness, and a bruise under the left eye. Staff and the ADON observed the resident on the floor, face down, making a gurgling sound and not responding right away. The resident was later evaluated at the hospital, where documentation noted assault, lip abrasion, contusion to the lip, and nasal contusion. Interviews with the ADON, DON, NP, and Assistant Administrator confirmed that staff did not maintain separation of the two residents after the first incident and did not escort the aggressive resident back to his/her hall, despite expectations and care plan directives to intervene and protect the safety of others. This failure to adequately supervise and separate the residents after the initial altercation led to the second, more serious physical assault and constituted a failure to protect the resident from abuse. The facility’s own abuse and neglect policy defined abuse as the willful infliction of injury and specifically included physical abuse such as hitting, punching, and kicking. The events described, including multiple punches to the face and kicks to the head, fit the facility’s definition of physical abuse. The residents’ statements, staff interviews, and medical records consistently describe the sequence of events: repeated requests for money, escalating verbal conflict, an initial physical assault, incomplete separation and supervision, and a subsequent, more severe assault near the nurse’s station. The combination of known behavioral histories, documented care plan interventions, and the lack of continuous supervision or enforced separation after the first incident directly contributed to the occurrence of the second assault and the resulting injuries, demonstrating the facility’s failure to protect the resident from physical abuse.
Failure to Provide Adequate Behavioral Health Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent staff to meet the behavioral health needs of residents, resulting in two physical altercations between two residents with significant psychiatric histories. One resident had diagnoses including schizophrenia, delusional disorder, and a history of social exclusion and rejection, with a PASRR indicating behaviors including physical aggression, poor impulse control, and triggers related to stealing. The other resident had schizoaffective disorder bipolar type, PTSD, anxiety, OCD, and schizophrenia, with a care plan noting a history of violence, impulsivity, lack of judgment, and triggers when feeling threatened. Both residents’ MDS assessments documented no behaviors, despite care plan information indicating behavioral risks. On the day of the incident, the two residents argued in the front hall outside one resident’s room, reportedly over money and the sale of items. During this first altercation, one resident punched the other in the head twice. Staff, including the ADON, intervened and separated them, with one resident returning to their room and the other walking toward their room on a separate, locked unit in the back hall. No staff were assigned to escort or monitor the resident returning to the back hall, and there was no documentation of behavioral intensive monitoring between the first and second incidents, despite the facility’s policy that residents requiring increased monitoring for behavioral or psychiatric issues should receive intensive or one-to-one monitoring with documentation in the medical record. A short time later, the residents encountered each other again near the nurse’s station. One resident confronted the other, reportedly grabbing the other’s shirt, and the same resident who initiated the earlier physical aggression punched the other resident in the face twice, causing the resident to fall to the floor, then kicked the resident in the head twice. Staff reported hearing a loud noise and then finding the resident on the floor by the nurse’s station. The injured resident experienced a bloody nose and loss of consciousness and was transported to the hospital for evaluation and treatment. Interviews with staff, including the CMT, ADON, DON, NP, and Assistant Administrator, confirmed that no staff escorted the resident back to the locked unit after the first altercation, that the door between the units did not always lock reliably, that residents from the back hall typically walked unescorted through the front hall to smoke, and that no one had been instructed to provide extra or intensive monitoring for either resident after the initial incident. These actions and inactions demonstrate the facility’s failure to implement its behavioral health and intensive monitoring policies to protect residents and address known behavioral health needs.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, who had diagnoses including bipolar disorder, major depressive disorder, schizoaffective-bipolar disorder, and anxiety disorder, was assaulted while sleeping by another resident with a history of schizoaffective disorder, bipolar disorder, unspecified psychosis, and anxiety disorder. The assault involved the use of fingernails and a broken pen, resulting in multiple facial lacerations of varying depths and redness on the left side of the victim's face. The incident was witnessed by staff, and law enforcement was called to the scene. Prior to the assault, the resident who was attacked had entered the assailant's room, accused them of theft, and disrupted their belongings, including tearing up a picture and putting shampoo on the bed. The assailant, angered by these actions, entered the other resident's room while they were sleeping and initiated the physical altercation. Staff responded to the incident after hearing screams and found the assailant on top of the victim, clawing at their face with fingernails and holding a broken pen. The victim sustained multiple scratches and lacerations, some deep enough to draw blood, and was sent to the hospital for evaluation and treatment. Interviews with staff and residents confirmed the sequence of events, with multiple staff members observing the physical altercation and the injuries sustained. The facility's investigation documented the altercation, the residents' behavioral histories, and the physical evidence of abuse. The incident was classified as abuse in the facility's investigation, and law enforcement issued a citation for assault to the resident who initiated the attack.
Physical Abuse of Resident by CNA During Behavioral Incident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) physically abused a resident during an altercation. The incident began when the resident, who had a history of impulse disorder, paranoid schizophrenia, and obsessive-compulsive personality disorder, became upset about not having a cigarette. The resident, described as severely cognitively impaired and with a history of physical aggression, was running toward a door when the CNA attempted to intervene by grabbing the resident from behind. The resident responded by striking the CNA in the face and pulling the CNA's hair. In response, the CNA struck the resident in the face with a closed fist, causing both to fall to the floor, with the CNA on top of the resident and continuing to swing at the resident with a closed fist. Multiple staff members, including another CNA and an LPN, witnessed the CNA on top of the resident, with the resident sustaining visible injuries such as a laceration and bleeding from the nose, a scratch under the left eye, and later confirmed acute avulsion fracture of the distal nasal bone. The altercation required intervention from several staff members to separate the CNA from the resident. Witnesses reported that the CNA continued to strike the resident even after both were on the floor, and staff described the incident as abuse, noting that the CNA's actions were excessive and not in line with de-escalation or non-physical intervention techniques outlined in facility policy. The facility's own policies emphasized the use of non-physical interventions and de-escalation as first-line responses to behavioral crises, and specifically prohibited the use of force or physical punishment. Despite these policies, the CNA engaged in physical violence against the resident, resulting in significant injury. The incident was reported to law enforcement as an assault, and medical evaluation confirmed the extent of the resident's injuries. Multiple interviews with staff and another resident corroborated that the CNA's actions constituted physical abuse.
Failure to Ensure Behavioral Health Training for Staff
Penalty
Summary
The facility failed to implement and maintain an effective behavioral health training program for all staff, as required by its own policies and facility assessment. Despite identifying 140 residents with behavioral health needs and 140 residents requiring long-term psychiatric management, documentation showed that several active employees, including a Certified Medication Technician, multiple CNAs, and an LPN, did not have completed behavioral health training. Additionally, one previous CNA involved in a resident incident had no documented behavioral health or CPI (Crisis Prevention Institute) training. Interviews with staff confirmed that some employees had not received specialized training since hire, were unsure how to respond to behavioral incidents, and did not understand facility codes related to behavioral emergencies. A specific incident involved a resident with a history of impulse disorder, paranoid schizophrenia, and obsessive-compulsive personality disorder, who was severely cognitively impaired. The resident had a care plan indicating a history of physical aggression and required staff to use de-escalation techniques and maintain personal space. During a behavioral crisis, a CNA without documented CPI training physically struck the resident multiple times after the resident pulled the CNA's hair. The altercation resulted in the resident sustaining a bloody nose and a bruise under the eye, and required intervention from other staff to separate the CNA from the resident. Record reviews and interviews revealed that the facility did not have an effective system to track behavioral health training prior to a certain date, and that some staff were allowed to work with residents or respond to behavioral emergencies without the required training. The facility's own policies required all staff, including non-nursing staff, to complete behavioral health and CPI training before working with residents, but this was not consistently enforced. The lack of training and documentation directly contributed to staff being unprepared to manage behavioral health crises, as evidenced by the incident involving the CNA and the resident.
Failure to Provide Physician-Ordered Pureed Diet in Correct Consistency
Penalty
Summary
The facility failed to provide a physician-ordered pureed diet in the correct consistency for one resident who required a pureed texture with nectar-thick liquids. The resident, who had a history of kidney disease, depression, anemia, heart disease, and a gastrostomy tube, was observed receiving a bowl of oatmeal that was lumpy and not of the required smooth, pureed consistency. Staff interviews revealed uncertainty about what pureed consistency should look like, with one CNA noting the oatmeal resembled regular oatmeal rather than the expected pudding-like texture. The cook responsible for preparing the meal admitted to not pureeing the oatmeal due to time constraints and demonstrated a lack of clear understanding regarding the proper preparation of pureed foods. Review of the facility's policy indicated that pureed foods should be prepared using standardized recipes, with appropriate liquids such as broth or milk, and should not be thinned with water. The policy also required that pureed foods have a smooth, applesauce-like consistency and retain the flavor of the original menu item. However, the cook reported using water and thickener when pureeing foods and was not certain about the correct texture. The dietary manager, new to the facility, had not yet assessed the staff's knowledge or observed the preparation process prior to the incident. There was also no evidence in the resident's medical record of a dietician or speech therapy assessment supporting any change from the prescribed pureed diet. Observations confirmed that the resident did not receive the prescribed pureed diet at breakfast, and staff interviews highlighted gaps in training and understanding of pureed food preparation. The resident reported difficulty eating the oatmeal and indicated a preference for softer foods that were easier to swallow. The deficiency was further underscored by the lack of documentation supporting any dietary waiver or change in the resident's prescribed diet, as well as the absence of proper monitoring and adherence to facility policy regarding pureed food preparation.
Failure to Maintain Professional Boundaries and Resident Dignity
Penalty
Summary
Facility staff failed to maintain professional boundaries and provide dignity and respect to two residents. On the specified date, a staff member, Cook A, hugged and kissed one resident on the cheek in the dining room and took possession of that resident's spending card, removing it from the premises. The resident had a history of multiple mental health diagnoses, including PTSD, schizoaffective disorder, and borderline personality disorder, and required a structured environment, supervision for safety, and financial management services. The resident was cognitively intact and had a guardian. The resident reported that Cook A frequently hugged female residents and that this was the first time Cook A had kissed them. The resident did not desire a relationship with Cook A and described the kiss as 'weird.' The resident's guardian was not notified about the incident or the removal of the spending card. Another resident, also with a history of mental health diagnoses including schizoaffective disorder, PTSD, and anxiety disorder, reported feeling uncomfortable after being hugged by Cook A in the dining room. This resident witnessed Cook A kissing the first resident and described additional inappropriate interactions, such as Cook A asking the first resident to go around the corner with them. The second resident was also cognitively intact and required protective oversight and assistance from staff for emotional and social needs. Multiple staff interviews and video surveillance confirmed that Cook A hugged and kissed the first resident and hugged the second resident in the dining room. Staff members, including the Dietary Manager, Human Resources Manager, and Staffing Coordinator, observed or were aware of the inappropriate conduct and reported it to administration. The incident was captured on camera, and staff confirmed that Cook A had previously been restricted from certain duties due to similar allegations. The facility's policies required staff to treat residents with dignity and respect, maintain professional boundaries, and not accept or remove residents' personal possessions without proper authorization.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the night in question, one resident asked another for a sexual act. When the request was refused, the first resident initially began to walk away but then returned and struck the other resident in the mouth, resulting in the loss of the victim's two top front teeth. The incident was not immediately reported to staff, and the injured resident did not inform anyone about the assault. The injury was only discovered the following morning when staff noticed the missing teeth. The resident who committed the abuse had a documented history of schizophrenia, psychotic disorder, anti-social personality disorder, delusional disorder, and severe substance use disorders. This resident also had a history of aggressive behaviors, including physical and verbal aggression, and required ongoing behavioral monitoring and support. The victim had diagnoses including sickle-cell disease without crisis, schizophrenia, and sexual dysfunction, and was described as minimally cognitively intact with moderate mood issues and no negative behaviors during the relevant assessment period. Staff interviews revealed that neither resident reported the incident at the time it occurred, and the charge nurse on duty was unaware of any altercation during the night. The staff only became aware of the abuse after observing the physical injury the next morning. The facility's own investigation concluded that the incident constituted abuse, as it resulted in injury and was unprovoked.
Failure to Maintain Full-Time Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time Licensed Social Worker (LSW) as required for facilities with more than 120 beds, affecting all residents in need of social services. The last full-time LSW left the facility on 5/23/25, and since then, there was no qualified individual consistently fulfilling the role. The facility census was 151 residents, and the absence of a full-time LSW resulted in lapses in required social services documentation, assessments, and participation in care planning for multiple residents with significant mental health and psychosocial needs. Record reviews for several residents revealed that there were no social worker progress notes or social services interventions documented for extended periods following the departure of the LSW. For example, one resident with diagnoses including schizophrenia and sickle-cell disease had no social worker notes from January through the present, and no evidence of social services involvement in critical processes such as sexual consent forms. Similar gaps were found for other residents with complex psychiatric and behavioral diagnoses, including a lack of social services assessments, absence from care plan meetings, and no input on important documentation such as sexual consent forms. Interviews with facility staff and external partners confirmed the deficiency. The administrator acknowledged the absence of a full-time LSW and stated that a consultant was only available for questions and not present daily or performing the full scope of LSW duties. The consultant LSW confirmed they were not acting as the facility's LSW and only provided limited assistance. The regional director of operations noted that a non-licensed staff member had temporarily filled the role, but this did not meet regulatory requirements. The Ombudsman reported not receiving required discharge logs for two months, which had previously been provided by the LSW, further evidencing the breakdown in social services processes.
Failure to Provide Safe Means for Sexual Expression and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to a dignified existence, self-determination, and safe sexual expression for three sampled residents who were sexually active. The facility's policy required that residents be informed of their rights, including the right to privacy, reasonable accommodation of preferences, and participation in social activities, provided these did not infringe on others' rights. Despite this, interviews and record reviews revealed that the facility did not provide access to condoms or a designated private area for residents to engage in consensual sexual activity. One resident, with a history of psychiatric disorders and a guardian, was found to have the capacity to consent to sexual activity but reported no interest in sexual activity and noted the absence of condoms and uncertainty about private spaces. Another resident, with multiple mental health diagnoses but no history of sexual inappropriateness, was also cognitively intact and expressed interest in sexual activity, stating that condoms were not available in the facility. A third resident, with a history of schizoaffective disorder and substance dependence in remission, also had the capacity to consent and expressed a desire for both condoms and a private space, recalling that such resources were previously available but no longer provided. Facility leadership acknowledged that while they had discussed providing condoms and private spaces, they did not implement these measures due to a perceived lack of expressed interest from residents. Interviews confirmed that residents had not been offered sexual health resources or education recently, and the facility had not pursued further action to support safe sexual activity, despite residents' rights and expressed needs.
Failure to Ensure Resident Access to Clean Clothing and Support Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination and choice by not ensuring that a resident had access to clean clothing, resulting in the resident wearing the same soiled clothes for two consecutive days. Observations revealed that the resident wore a purple pullover shirt with smudges and food stains, and oversized jeans that repeatedly fell down, on two consecutive days. Upon inspection of the resident's room, no clothing was found in the closet, drawers, or hamper. Interviews with the resident, family, and staff confirmed that the resident had no clean clothes available and had reported missing clothing to the facility. The resident had a history of epilepsy, paranoid schizophrenia, hallucinations, personality disorder, anxiety disorder, delusional disorder, and a very low level of personal hygiene. The care plan indicated the resident required supervision and assistance with personal hygiene and activities of daily living. Despite this, the resident was left without clean clothing, and family members reported multiple instances of the resident having no clothes in the room and wearing soiled garments. The resident's friend, who sometimes assisted with laundry and personal care, also confirmed the lack of available clothing and noted that the only clothes present at one point were not the resident's. Staff interviews revealed that when a resident lacked clothing, the expectation was for staff to obtain clothes from the basement, but this was not consistently done. Some staff were unaware of the resident's lack of clothing, while others acknowledged that clothing was not always transferred to residents' rooms as required. The administrator and DON both stated that residents should have access to clean clothes and that missing clothing should be replaced, but in this case, the resident was left without appropriate clothing for an extended period.
Failure to Allow Resident Visitation and Lack of Written Visitor Policy
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at the time of their choosing. Specifically, a resident's friend and family member attempted to visit the resident in the evening, but were denied access by the Director of Nursing (DON). The DON stated that the visitors were not allowed on the unit because of a previous verbal altercation and concerns about the unit becoming 'worked up.' The DON also did not facilitate a visit in the lobby, citing that the resident was in bed, despite the resident later stating they would have liked to receive visitors that evening. The resident in question had mild cognitive impairment and was independent in meeting emotional, intellectual, physical, and social needs, according to their care plan and assessment records. The resident's friend was noted to be very involved in their care and visited several times per week, with no negative interactions reported by multiple staff members, including a Certified Medication Technician, a Certified Nurse Assistant, and an LPN. The resident's guardian also expressed the expectation that the resident's right to visitors be upheld and that staff should facilitate visits if access to the unit is restricted. Additionally, the facility did not have a written visitor policy in place, as confirmed by the Administrator. The lack of a visitor policy and the denial of visitation rights to the resident's chosen visitors constituted a failure to protect and promote the resident's rights as outlined in the facility's own policy and federal requirements.
Failure to Maintain Cleanliness and Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions and inadequate hot water temperatures in several resident rooms on a gender-specific unit. Hot water temperatures in multiple rooms were measured at approximately 76 degrees Fahrenheit, well below the minimum required 105 degrees Fahrenheit, and these issues persisted over several days. Residents reported that they had informed staff about the lack of hot water and clogged sinks, but no effective action was taken to resolve these concerns. Interviews with staff confirmed that maintenance was unaware of the hot water issue and that a new system for communicating maintenance needs had not yet been implemented. Observations in resident rooms revealed significant cleanliness and maintenance issues, including sinks clogged with standing brown or gray water, dirty countertops with brown substances, soiled personal care items, and bathrooms with brown splatter, missing fixtures, and dirty floors. In some cases, disposable briefs were found submerged in toilet water, and there was evidence of water damage such as sagging ceiling tiles and water dripping from the roof. The hallways and common areas on the unit were also found to be soiled, with dried substances and build-up along the floors and door frames. Interviews with residents and staff indicated that housekeeping services had been inconsistent, with some areas not being cleaned for weeks due to staffing shortages and a recent transition from a third-party cleaning company back to in-house staff. Direct care staff, including CNAs and CMTs, reported being expected to perform cleaning duties in addition to their primary responsibilities, but stated they did not have sufficient time to do so. The lack of regular housekeeping and maintenance contributed to the ongoing unsanitary conditions and failure to provide a safe, clean, and homelike environment as required by facility policy and resident rights.
Failure to Reassess and Coordinate Discharge for Hospitalized Residents
Penalty
Summary
The facility failed to adhere to all required components of the discharge process for three residents who were found to be medically stable and no longer a safety risk after being transferred to the hospital. Documentation and interviews revealed that, although immediate discharge notices were provided to guardians and the ombudsman, the facility did not reassess the residents' conditions after hospitalization to determine if their needs could be met upon return. The facility also did not collaborate with guardians or hospital staff to facilitate the residents' return or alternative placement, despite requests and appeals from guardians and hospital case managers. For each of the three residents, the facility issued immediate discharge notices citing health and safety concerns, and transferred the residents to the hospital. The discharge letters included required information such as the reason for discharge, appeal rights, and ombudsman contact details. However, after the residents were stabilized in the hospital and deemed ready for return, the facility refused to reassess or accept them back, and did not engage in further communication or planning with the hospital or guardians regarding their return or alternative placement. Guardians and hospital staff reported a lack of follow-up and communication from the facility, and appeals were filed in response to the discharges. The residents involved had significant psychiatric and medical histories, including diagnoses such as vascular dementia, paranoid schizophrenia, bipolar disorder, and Wernicke's encephalopathy. Despite being medically cleared for return by hospital staff, the facility maintained its decision not to readmit the residents, and did not provide evidence of reassessment or efforts to ensure safe and appropriate discharge planning. The ombudsman confirmed receipt of discharge notices and ongoing appeals, with all three residents remaining in the hospital awaiting further placement.
Failure to Maintain Sanitary and Functional Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functioning environment for residents, as evidenced by multiple rooms with sinks that were either clogged or filled with discolored standing water. Observations revealed that in several resident rooms, sinks did not drain after running water for two minutes, and in some cases, the water in the sinks was brown or gray with visible sediment. Toilets in these rooms also contained discolored water and, in one instance, an adult incontinent brief was found in the toilet. These issues persisted for several days, impacting nine residents, some of whom reported the problems to staff without resolution. Residents affected by these deficiencies included individuals with significant mental health diagnoses such as schizoaffective disorder, bipolar type, agoraphobia with panic disorder, and post-traumatic stress disorder. At least one resident was cognitively intact and reported the issue to staff, while another, who was moderately cognitively impaired, stated that the sink had been clogged for two or three days and that staff had attempted to use a plunger to resolve the issue. Staff interviews confirmed that clogged sinks and toilets were a recurring problem, with residents reportedly placing items such as ramen noodles, tea bags, toilet paper, and sanitary pads in the plumbing, contributing to the blockages. The facility's maintenance and communication systems were found to be inadequate in addressing these ongoing environmental concerns. The Maintenance Director reported being the only maintenance staff member and stated that a new system for reporting maintenance needs had not yet been implemented. Staff were unclear about the process for reporting maintenance issues, with some relying on communication books at nurse stations and others reporting verbally to nurses or administration. The Department Manager and DON acknowledged that the clogged sinks and toilets had been a persistent issue, and that maintenance was not always promptly notified or able to resolve the problems in a timely manner.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in multiple incidents of sexual and physical abuse. One resident, who was cognitively intact but physically dependent due to a stroke, reported being sexually abused by a roommate with a history of severe dementia and prior sex offender status. Despite the resident immediately reporting the first incident to a CNA, and the CNA informing the LPN, no immediate action was taken to separate the residents or investigate the allegation. As a result, the abuse continued two more times during the same night, with the victim remaining in the same room as the alleged perpetrator until the following morning when the DON became aware and intervened. In a separate incident, another resident with quadriplegia and cognitive intactness was physically abused by a roommate who had a history of bipolar disorder, TBI, and depression. The abusive event occurred when the roommate threw a hard plastic cup at the resident, causing a deep cut to the lip that required sutures. The incident was reported to staff, and the police were notified. The resident was sent to the hospital for treatment. Both residents involved in the altercation had no prior history of negative behaviors or altercations, and staff care plans included monitoring for escalation and providing support for coping skills. The facility's policies required immediate removal of alleged perpetrators and interventions to protect residents from abuse, but these were not followed in the cases described. Staff failed to escalate reports of abuse and did not implement protective interventions in a timely manner, resulting in repeated abuse and injury to the residents involved. The deficiencies were identified through observation, interviews, and record reviews, and were determined to be at the immediate jeopardy level at the time of the survey.
Staff Used Inappropriate Language Toward Resident
Penalty
Summary
A Certified Medication Technician (CMT) addressed a resident in an inappropriate and disrespectful manner by using foul language in the main dining room. The incident occurred when the resident, who has a history of dementia with behavioral disturbance and traumatic brain injury but was assessed as cognitively intact, made an unintelligible or potentially inappropriate comment toward the CMT. In response, the CMT told the resident, "Shut your ass up!" This exchange was overheard by the facility Administrator and another CMT, both of whom confirmed the inappropriate language used by the staff member. The resident involved was admitted with diagnoses including dementia with behavioral disturbance and traumatic brain injury, but had no negative behaviors documented during the recent assessment period. The resident's care plan instructed staff to remain calm, avoid confrontation, and respond to inappropriate comments by setting clear limits and maintaining professionalism. Despite these guidelines, the CMT's response did not align with the care plan or facility policies on dignity, respect, and professional conduct.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse in a timely manner for one resident. The incident began when a resident, who had a history of major depressive disorder, anxiety, psychotic disorder, and was cognitively intact, reported to a CNA that another resident had fondled their genital area over their underwear around midnight. The CNA informed the LPN, but the allegation was not escalated to administrative staff as required by facility policy. The resident experienced repeated incidents throughout the night, including further unwanted contact and inappropriate behavior from the alleged perpetrator, and remained in the same room as the accused resident until morning. The resident's written and verbal statements confirmed that they reported the abuse to the CNA multiple times during the night, and the CNA stated they relayed the information to the LPN. However, the LPN did not take immediate action, citing being busy with other tasks and forgetting to notify the next shift or administrative staff. The LPN admitted to not reporting the abuse and acknowledged that they should have prioritized the report. The DON only became aware of the incident during morning rounds, several hours after the initial report was made. The facility's policy required immediate reporting of all alleged violations to a superior staff member, with the licensed nurse responsible for escalating the report to the DON. Interviews with the DON, Administrator, and Nurse Practitioner all indicated that the expectation was for immediate notification to administrative staff, which did not occur in this case. The failure to follow established reporting procedures resulted in a delay in addressing the resident's allegation of sexual abuse.
Failure to Protect Residents from Physical Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in several incidents involving both staff-to-resident and resident-to-resident altercations. In one incident, a cognitively intact resident with schizophrenia and psychosis was physically pushed by an activity aide into a washer and then against a wall, where the aide held the resident in place with a forearm against the chest, causing a large bruise and abrasion. Multiple witnesses, including other residents and staff, confirmed the physical altercation, and the resident expressed a desire to press charges. The staff present did not intervene to stop the abuse, and the incident was not initially recognized as abuse by the facility administration until after the injury was discovered. In another event, two residents with significant psychiatric histories and behavioral challenges engaged in a violent altercation after one resident became agitated following an incident with a staff member. The residents ended up on the floor, hitting, pulling hair, and biting, resulting in visible injuries including bruising, a facial bite, and head trauma. Staff failed to provide necessary supervision and did not intervene to prevent the altercation, despite one resident having just exhibited aggressive behavior toward a staff member. The care plans for both residents indicated a need for close monitoring and behavioral interventions, which were not implemented at the time of the incident. Additional incidents included a resident being attacked and having their head banged on the ground by another resident while not under required 1-1 staff oversight, and another resident being struck with a chair thrown by a peer, resulting in physical injuries. The facility's policies and care plans outlined the need for de-escalation, supervision, and protection from abuse, but these were not followed, leading to multiple residents sustaining injuries and expressing fear for their safety.
Failure to Investigate Allegations of Abuse and Assess Capacity to Consent
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving three residents. In two cases, two residents with legal guardians and complex psychiatric histories were observed engaging in sexual activity in a public area. The facility did not complete the required capacity to consent assessments, as the forms were missing critical information such as scoring, documentation, and signatures from guardians and evaluators. There was no evidence of a comprehensive investigation to determine whether the incident constituted sexual abuse, and the facility did not interview all potential witnesses or consult with psychiatric professionals as required by policy. Additionally, the facility did not investigate an allegation that one resident provided another with a medication for anxiety, which was not prescribed to the recipient. The incident was reported by the involved residents, but there was no documentation of an investigation to determine the circumstances or whether abuse or neglect occurred. The facility's policies required prompt and thorough investigation of all abuse allegations, including witness interviews, medical record reviews, and administrative review, but these steps were not completed. In a separate incident, a resident with dementia and psychiatric diagnoses alleged that a CNA hit them in the face. The facility's investigation was limited to interviews with the resident, one other resident, and the accused CNA, but did not include interviews with all staff present or other potential witnesses. There was no documentation identifying the alleged perpetrator, and the investigation did not include written statements or a comprehensive review of the incident. Physical observations later confirmed discoloration on the resident's cheek, but the facility did not document a thorough assessment or investigation into the cause.
Failure to Maintain Required 1-1 Supervision for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure the safety of a resident with significant behavioral health needs by not maintaining required 1-1 supervision as outlined in the resident's care plan and facility policy. The resident had a complex psychiatric history, including borderline personality disorder, depression, schizoaffective disorder, anxiety, and a history of self-harm and suicidal ideation. The care plan and individualized service plan specified continuous 1-1 monitoring, with staff required to remain within eyesight and arms reach of the resident at all times, and to intervene as needed to prevent harm. Despite these requirements, multiple instances were documented where staff assigned to 1-1 supervision were not present or not attentive to the resident. On several occasions, there was no documentation of 1-1 supervision, and staff were observed sitting away from the resident, engaging in unrelated activities, or not being within the required proximity. During one incident, the resident was assaulted by another resident while on the phone at the nursing station, and the assigned 1-1 staff was not close enough to intervene. The resident sustained a head injury and required hospital treatment. Staff interviews confirmed that the 1-1 was not consistently maintained, and some staff lacked necessary crisis intervention training. Further review revealed additional lapses, such as the resident being left alone in their room with the door closed, and staff assigned to 1-1 supervision being responsible for other duties or residents. The Director of Nursing and other facility leaders acknowledged challenges with staffing and confirmed that 1-1 supervision protocols were not followed, particularly during overnight shifts. These failures resulted in the resident experiencing harm and feeling unsafe, as well as additional incidents of self-harm when left unsupervised.
Failure to Notify Guardian of Resident Transfer
Penalty
Summary
Facility staff failed to notify the legal guardian of a resident with multiple psychiatric and medical diagnoses, including schizophrenia, narcissistic personality disorder, unspecified dementia, anxiety disorder, diabetes type II, and a colostomy, when the resident experienced a change in condition and was transferred to the hospital. The resident, who had a guardian assigned to assist with decision-making, called 911 and was transported to the hospital, but there was no documentation that the guardian was informed of this transfer as required by facility policy. Interviews with facility staff, including an LPN, the DON, and the Administrator, confirmed that the guardian was not notified of the resident's transfer, despite the expectation and policy that such notification should occur whenever a resident with a guardian experiences a significant change in condition or is transferred out of the facility. The guardian's office also confirmed they were not contacted and would have expected to be notified in this situation.
Resident Restrained on Floor by Staff and Another Resident During Behavioral Incident
Penalty
Summary
A deficiency occurred when a resident with multiple psychiatric and neurocognitive diagnoses, including psychotic disorder, schizoaffective disorder, and a history of aggressive behaviors, was physically restrained by staff and another resident. The incident began after the resident became agitated upon discovering their room had been cleaned and their laundry removed, leading to a confrontation with an LPN. The resident struck the LPN, who then attempted to block further aggression, resulting in both the LPN and the resident falling to the floor. During this altercation, the LPN and a Certified Medication Technician (CMT) held the resident's arms, while another resident held the agitated resident's legs down. Facility video footage and staff interviews confirmed that the resident was held on the floor by both staff and another resident. The staff involved did not redirect other residents away from the escalating situation, and one resident actively participated in restraining the agitated resident. The facility's own policies and staff training, including CPI (Crisis Prevention Institute) guidelines, prohibit the use of floor holds and the involvement of other residents in restraint situations. Multiple staff, including the DON and Administrator, acknowledged that residents should never be involved in restraining another resident and that holding a resident down is not appropriate. The resident's care plan indicated a need for de-escalation strategies and avoidance of physical confrontation, but these were not followed during the incident. The staff failed to implement non-restrictive interventions and did not prevent another resident from participating in the restraint. The event was not considered abuse or neglect by the facility after internal review, but it was determined that the use of physical restraint and the involvement of another resident constituted a violation of resident rights and facility policy.
Failure to Notify Physician and Responsible Parties of Missed Medications
Penalty
Summary
The facility failed to notify physicians and resident representatives or legal guardians when three residents did not receive their prescribed medications. Facility policy required notification of clinicians and responsible parties in the event of medication unavailability or errors, but documentation and interviews revealed that this did not occur for the affected residents. The issue was identified through record reviews and staff and resident interviews, which consistently showed a lack of communication to the appropriate parties when medications were not administered as ordered. One resident with severe cognitive impairment and diagnoses including schizophrenia and sexual disorder did not receive multiple prescribed medications, such as Olanzapine, Medroxyprogesterone, and Quetiapine, on several occasions. There was no documentation that the resident's physician or guardian was notified of these missed doses. The resident expressed awareness of not receiving medications and a willingness to take them if available. Another resident, also severely cognitively impaired with schizophrenia and sexual dysfunction, experienced repeated missed doses of Paxil, with progress notes indicating the medication was not given and nurses were notified, but again, there was no evidence that the physician or guardian was informed. A third resident, who was cognitively intact and had multiple psychiatric and medical diagnoses, missed several medications over multiple days, including Restoril, Atenolol, Lacosamide, and Prazosin. Progress notes indicated the medications were not available and nurses were notified, but there was no documentation of physician or guardian notification. Staff interviews confirmed that while nurses and pharmacy were sometimes notified about missing medications, the required notifications to physicians and guardians did not occur. The nurse practitioner and administrator both stated they were not informed about the missed medications, and the administrator expected such notifications to be made.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect four residents from abuse when two separate incidents of resident-to-resident physical altercations occurred. In the first incident, one resident entered another resident's room and began hitting the resident, who then retaliated, resulting in both residents ending up on the floor before staff intervened. Both residents involved had a history of significant psychiatric diagnoses, including schizophrenia, antisocial personality disorder, and intermittent explosive disorder, with documented behavioral issues such as aggression, hallucinations, and poor impulse control. The incident was witnessed by staff, and interviews with the LPN, Unit Manager, Nurse Practitioner, DON, and Administrator all confirmed that the event met the definition of abuse according to facility policy and state statute. In the second incident, another resident entered a peer's room and struck the resident, who then responded physically. Staff intervened to separate the residents. One resident sustained facial bruising and was sent to the hospital for medical evaluation, while the other was sent for psychiatric evaluation and admitted for inpatient psychiatric treatment. Both residents involved in this altercation also had documented psychiatric conditions, including paranoid schizophrenia, antisocial personality disorder, and schizoaffective disorder, and were cognitively intact at the time of the incident. Interviews with staff and the residents confirmed that the altercation was intentional and met the criteria for abuse. The facility's own policies on abuse and resident rights require immediate reporting and protection from all forms of abuse, including physical abuse, regardless of the residents' mental or physical conditions. Despite these policies and the known behavioral histories of the residents involved, the facility did not prevent the physical altercations from occurring. The events were confirmed through interviews, record reviews, and facility investigations, with staff and administration acknowledging that the incidents constituted abuse as defined by both facility policy and state regulations.
Failure to Administer Behavioral Health Medications Leads to Adverse Resident Behaviors
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to three residents with significant mental health diagnoses and behavioral challenges. Specifically, the facility did not ensure the administration of prescribed medications for mental health and behavioral management, as evidenced by multiple documented instances where residents did not receive their ordered medications for extended periods. This included medications critical for managing schizophrenia, hypersexuality, and other behavioral symptoms. Staff interviews and progress notes confirmed that medications such as Paxil, Seroquel, and others were not administered due to issues with pharmacy delivery, lack of follow-up on prior authorizations, and breakdowns in communication between medication technicians, nurses, and management. As a result of these medication lapses, two residents with histories of hypersexuality and poor impulse control engaged in sexually charged behaviors in a community shower room, refusing staff redirection. Both residents had documented histories of sexually inappropriate behavior and required close monitoring and medication management as part of their care plans. Staff and residents reported that the absence of these medications contributed to the escalation of sexual behaviors, and staff were aware of the ongoing medication shortages but were unable to resolve them in a timely manner. The facility's own policies required the administration and monitoring of behavioral health medications as part of person-centered care, but these were not followed. A third resident, with a complex psychiatric history including schizophrenia, PTSD, and intermittent explosive disorder, also experienced multiple days without critical medications for both mental health and seizure management. During this period, the resident exhibited escalating aggressive behaviors, including physical altercations with peers and property destruction, ultimately resulting in a psychiatric evaluation at a hospital. Staff interviews confirmed that the lack of medication could have contributed to these behaviors, and there was confusion and lack of accountability regarding who was responsible for ensuring medication availability and administration. The facility's failure to provide necessary behavioral health services and to administer medications as ordered directly led to adverse behavioral events among these residents.
Failure to Administer Prescribed Medications Resulting in Behavioral Exacerbations
Penalty
Summary
The facility failed to ensure that three residents with chronic medical and mental health diagnoses received their prescribed medications, resulting in exacerbation of behaviors for all three. For each resident, there were multiple documented instances where medications for conditions such as schizophrenia, hypersexuality, and seizure disorders were not administered as ordered. The medication administration records and progress notes indicated that medications including antipsychotics, mood stabilizers, and other essential drugs were not available or not given over several days, with no documentation that the residents' physicians or guardians were notified of these omissions. For one resident with schizoaffective disorder and a history of hypersexual behavior, medications such as Olanzapine, Quetiapine, and Medroxyprogesterone were not administered as ordered, and there was no evidence of physician or guardian notification. Staff interviews revealed that the resident was aware of not receiving medications and that pharmacy delivery issues and incomplete prior authorizations contributed to the lapses. The nurse practitioner and DON confirmed that they were not informed of the missed doses, and both acknowledged that missing these medications could negatively impact the resident's mental health and behavior management. Another resident with schizophrenia and sexual dysfunction also missed multiple doses of Paxil, with progress notes and staff interviews confirming that the medication was out of stock for an extended period. Staff reported reordering the medication and notifying nurses, but there was no documentation of physician or guardian notification. The resident and staff observed increased behavioral issues during the period without medication. A third resident with multiple psychiatric and neurological diagnoses, including seizure disorder, was also without several prescribed medications for up to a week, leading to behavioral incidents and seizure activity. Staff interviews indicated confusion over responsibility for medication audits and notification procedures, and again, there was no documentation that the physician or responsible party was informed of the missed medications.
Unsecured Medication Carts Lead to Resident Access and Ingestion of Medications
Penalty
Summary
The facility failed to ensure that medications were securely stored, resulting in two medication carts being left unlocked and unattended on two separate occasions. As a result, four residents were able to access and obtain medications from the carts. Specifically, three residents accessed the unlocked cart and obtained medications including Metformin, Seroquel, and Buspirone, while a fourth resident accessed the narcotic box and took sixteen 5 mg tablets of Oxycodone, later admitting to ingesting eleven of them. Video evidence and written statements confirmed that the medication carts were left unattended and unlocked, allowing residents to remove medication cards and conceal them under their clothing. The residents involved had significant histories of substance abuse, psychiatric disorders, and behavioral issues, as documented in their PASRR assessments and care plans. These care plans specifically required that medications be administered only by staff in designated areas and that medication carts never be left unattended or unlocked. Despite these precautions, staff failed to maintain direct supervision of the medication carts and did not secure the carts or keys as required by facility policy. Staff interviews revealed confusion and lack of clarity regarding who was responsible for the cart at the time, with some staff members denying responsibility and others admitting to leaving the cart or keys unattended while performing other tasks. The incidents were further corroborated by resident and staff interviews, written statements, and review of facility video footage. Residents described how they took advantage of the unlocked carts to obtain medications, and staff acknowledged lapses in following medication storage protocols. The events led to unauthorized access and ingestion of medications, including controlled substances, by residents with known vulnerabilities and histories of substance abuse.
Inadequate Behavioral Health Care and Supervision
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with behavioral health needs and a history of PTSD, who displayed self-harming behaviors. The resident was hospitalized due to psychiatric needs after using a disposable razor blade to cut their forearm. Upon returning to the facility, the resident required one-on-one supervision, which was inconsistently applied. The facility did not have a system in place to ensure the interdisciplinary team (IDT) was involved in assessing the resident's needs related to supervision and participating in decision-making prior to implementing changes in the resident's care. The resident was removed from one-on-one supervision without input from the IDT team and subsequently self-harmed again, requiring emergency room treatment. The facility's assessment indicated the ability to treat various psychiatric and mood disorders, and the use of the IDT to discuss changes in residents' care. However, the facility failed to consistently implement the resident's plan of care related to behavioral services. The resident had a history of mental illness, including schizoaffective disorder, bipolar disorder, PTSD, and other conditions, and had been admitted to psychiatric hospitals multiple times. Despite this, the facility did not hold IDT meetings regarding the resident's increase in behaviors, such as screaming at staff and peers, threatening staff, and being physically aggressive. The resident's care plan directed staff to be aware of triggers and provide structure, but the facility staff did not consistently follow these directives. The resident's supervision level was changed from one-on-one staff observations to hourly face checks without proper IDT documentation or meetings. The facility staff failed to ensure no items were available to the resident that could be used for self-harm, leading to another self-harming incident. The facility's lack of consistent supervision and failure to involve the IDT in decision-making contributed to the resident's continued self-harming behaviors.
Failure to Protect Residents from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from physical abuse by staff members. In one incident, a resident with a history of schizophrenia and schizoaffective disorder was involved in a physical altercation with a CNA. The CNA and the resident exchanged punches, fell to the floor, and continued fighting while two other CNAs observed but did not intervene. After staff initially separated them, the CNA broke free from staff and struck the resident in the face multiple times, resulting in visible injuries including a cut above the eye, bruising, and a broken nose. The resident was sent to the hospital for evaluation and treatment of these injuries. Interviews and video footage confirmed that staff failed to use appropriate de-escalation techniques and that agency CNAs did not intervene due to lack of facility-specific training. In a separate incident, another resident with multiple psychiatric and developmental diagnoses, including schizophrenia, PTSD, and moderate intellectual disability, was physically abused by a hall monitor. The resident, after becoming agitated by a comment made by the hall monitor, ran toward the staff member and initiated a physical altercation. The hall monitor responded by striking the resident, and both exchanged punches and fell to the floor. Other staff and residents intervened to separate them. Video footage and witness statements confirmed that the staff member retaliated physically against the resident, which was classified as abuse, even though the resident did not sustain visible injuries. Both incidents involved staff members who had received training on abuse and neglect, yet failed to follow protocols and used physical force against residents. The facility's own policies defined such actions as abuse. In both cases, staff failed to use appropriate behavioral management and de-escalation strategies, and in the first incident, additional staff failed to intervene to stop the abuse. The events were substantiated through video evidence, witness statements, and interviews with staff and residents.
Failure to Prevent Resident Access to Hazardous Sharps Resulting in Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to follow established protocols for the management and supervision of disposable razors, resulting in a resident obtaining a razor and using it to inflict a superficial cut on their left forearm. The facility had implemented a new protocol several weeks prior, requiring disposable razors to be stored in Central Supply, accessible only by the charge nurse, with CNAs required to request razors, supervise residents during shaving, and return razors to the charge nurse for proper disposal. Despite this protocol, a resident with a history of self-harm and multiple psychiatric diagnoses was able to access a razor without supervision and use it to harm themselves. The resident involved had a complex psychiatric history, including schizoaffective disorder, bipolar disorder, psychotic disorder, PTSD, anti-social personality disorder, polysubstance dependence, ADHD, adjustment disorder, major depressive disorder, and mild intellectual disability. The care plan for this resident included specific interventions to prevent self-harm, such as ensuring no items were available that could be used for self-injury, observing the resident during shaving, and collecting and disposing of razors immediately after use. Despite these measures, the resident reported having hidden a disposable razor for several days or weeks and was able to break the plastic covering to access the blade, which was then used to cut their forearm. Interviews with staff revealed that the new razor protocol was in place and that staff had been educated on it, but it was unclear how the resident obtained the razor. Staff did not observe the resident shaving, and the resident was able to conceal the razor after use. The incident was discovered when the resident's roommate alerted staff, and the resident subsequently presented with a bleeding wound. The facility was unable to determine whether the razor had been hidden prior to the new protocol or was obtained in violation of the protocol. The event demonstrated a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents, as required by facility policy.
Deficiency in Dementia Care for Wandering Resident
Penalty
Summary
The facility failed to implement effective interventions for a resident diagnosed with dementia, leading to multiple incidents of wandering and inappropriate interactions with other residents. The resident, who was admitted with Alzheimer's disease and cognitive communication deficits, frequently wandered into other residents' rooms, causing distress and potential safety concerns. Despite being identified as at risk for wandering, the care plan lacked specific interventions to address the resident's behavior, and staff were not adequately trained or informed on how to manage the situation effectively. The resident's wandering behavior resulted in several incidents, including physical aggression towards other residents. On one occasion, the resident entered another resident's room and attempted to take personal belongings, leading to a confrontation. The facility's investigation noted that the incident was not preventable due to the resident's history, yet there was a lack of proactive measures to prevent such occurrences. Staff interviews revealed inconsistencies in the approach to managing the resident's wandering, with some staff members unsure of the specific interventions to employ. The facility's policy on elopements and wandering residents emphasized the need for a systematic approach to monitoring and managing at-risk residents, but this was not effectively implemented. The interdisciplinary team failed to develop a person-centered care plan with clear interventions, and there was inadequate communication and training among staff. As a result, the resident's behavior continued to affect the safety and well-being of other residents, highlighting a deficiency in the facility's dementia care practices.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #4, who was cognitively intact and required substantial assistance with personal hygiene due to conditions such as Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, depression, and severe obesity. The resident reported that a Certified Nursing Assistant (CNA), referred to as CNA E, was rough and rude during care, making the resident feel belittled. The resident had recorded interactions with CNA E, which revealed that CNA E spoke in a gruff and disrespectful manner, questioning the resident's lack of supplies and being dismissive of the resident's discomfort during incontinence care. The resident's care plan indicated a risk for skin integrity impairment due to refusal to get out of bed and frequent bowel incontinence. Despite this, CNA E did not communicate effectively or gently during care, as evidenced by audio recordings where the resident expressed pain and discomfort. CNA E was heard questioning the resident's lack of supplies and dismissing the resident's expressions of pain, suggesting that the resident could perform tasks independently despite the resident's inability to do so. During an interview, the facility's Administrator acknowledged the inappropriate behavior of CNA E, describing it as brusk and indicating a need for education on proper communication and care techniques. The resident expressed a lack of trust in the facility's staff, which was compounded by having incorrect contact information for the Administrator. The facility's failure to ensure respectful and dignified treatment of the resident by CNA E constituted a deficiency in maintaining resident dignity and respect.
Failure to Notify Guardian of Resident's Hospitalization and Treatment
Penalty
Summary
The facility failed to notify the guardian of a resident with schizophrenia about significant changes in the resident's condition. The resident, who had a legal guardian due to mental illness, was involved in an incident where they became verbally aggressive, expressed pain, and were sent to the hospital for medical attention. Although the facility's policy required immediate notification of the resident's legal representative in such situations, there was no documentation that the guardian was informed about the resident's hospitalization, the abscess on the resident's forearm, or the new order for antibiotics. The Licensed Practical Nurse (LPN) attempted to contact the guardian by phone but did not follow up after leaving a voicemail, and there was uncertainty about which phone number was used. The guardian later reported not receiving any voicemail or notification about the resident's hospitalization or medical treatment. Despite providing the facility with multiple contact numbers and requesting documentation from the hospitalization, the guardian was not informed of the resident's return from the hospital or the medical procedures performed.
Resident Elopement Due to Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a secure environment for a resident who left the facility without permission from their legal guardian. The resident, who had a history of elopement and significant mental illness, was able to leave the facility with an individual they claimed was their spouse. The receptionist allowed the resident to leave without verifying the necessary permissions or completing the required outside pass form. This incident occurred despite the facility's policy requiring guardian consent and specific procedures for residents leaving the premises. The resident had a documented history of elopement and was considered a high risk for such behavior. They had previously fled a residential care facility, resulting in incidents of assault and vehicle wreckage. The resident's care plan identified them as a very high risk for elopement, requiring close monitoring and supervision. However, the facility failed to conduct an elopement assessment upon the resident's admission and did not perform quarterly assessments as required. On the day of the incident, the resident expressed a desire to leave with someone they identified as their spouse. Despite the lack of an approved outside pass and the absence of guardian consent, the receptionist allowed the resident to leave. The facility's staff, including the charge nurse and other personnel, were unaware of any approved pass for the resident. The receptionist did not follow the protocol of verifying the pass with the Administrator or Social Worker, leading to the resident's unauthorized departure.
Resident Assault Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident struck them in the face, resulting in a broken nose. The incident occurred when the resident was standing in the hallway and was approached by another resident who punched them, causing significant injury. The facility's investigation concluded that the injury was not caused by abuse or neglect and was not preventable, despite the serious nature of the incident. The resident who was attacked had a complex medical history, including mood disorder due to traumatic brain injury, schizophrenia, and other mental health conditions. They were known to have behavioral challenges and required protective oversight. The resident who committed the assault also had a history of mental illness, including schizophrenia and bipolar disorder, and had exhibited aggressive behaviors in the past. Both residents were considered cognitively intact according to their assessments. The incident was unwitnessed, and there was no video evidence available. The staff present at the time did not observe any prior interaction or triggers between the two residents that day. The resident who committed the assault was reportedly upset due to family issues, which may have contributed to their behavior. The facility's staff were present in the hall, but the incident occurred unexpectedly, and the staff did not foresee the aggressive act.
Facility Fails to Maintain Safe and Comfortable Environment Due to A/C Issues
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not ensuring that the indoor air temperatures of resident rooms were kept between 71.0°F and 81.0°F. Observations revealed that room temperatures ranged from 82.0°F to 86.7°F, affecting 20 sampled residents. Several residents reported discomfort due to the heat, with one resident having to sleep in the common area and another experiencing distress due to a heart condition. The facility lacked a comprehensive monitoring system for air temperatures and did not maintain proper documentation for ongoing maintenance of cooling units. The facility's Emergency Operations Plan outlined procedures for HVAC failures, including notifying the charge nurse and facilities manager, contacting repair companies, and ensuring resident comfort and safety during extreme heat. However, the facility did not adhere to these procedures, as evidenced by the lack of timely repairs and inadequate monitoring of room temperatures. The A/C repair log indicated that a significant number of resident room A/C units were not functioning properly, with issues such as no power, mild air, and panel errors. Interviews with staff, including the DON and Regional Maintenance Manager, revealed that the facility was aware of the A/C issues but failed to take adequate action to resolve them. The Maintenance Director had been taking random temperature checks, but there was no systematic approach to monitoring and addressing the high temperatures. Residents expressed their discomfort and reported the issues to staff, but the facility did not effectively address their concerns, leading to an environment that was not safe, clean, comfortable, or homelike.
Failure to Deescalate Resident with Behavioral Difficulties
Penalty
Summary
The facility failed to provide appropriate treatment and services to deescalate a resident who was displaying emotional and behavioral adjustment difficulties. The resident, who had a history of mental disorders including schizophrenia, psychosis, personality disorder, OCD, mood disorder, and PTSD, was involved in an incident with an LPN. The resident's care plan included strategies for managing behaviors and mental illness, such as attending therapeutic groups, individual counseling, and staff awareness of triggers and coping skills. However, during the incident, these strategies were not effectively implemented. The incident occurred when the resident, frustrated over a missing check, approached the LPN after using the phone. The resident pushed the LPN, leading to a physical altercation where both parties swatted at each other. The LPN, instead of de-escalating the situation, stepped toward the resident and pushed them, causing the resident to fall. The resident had a history of generalized pain and complained of knee pain after the fall, although no injury was found. Interviews with the LPN and the Director of Nursing revealed that the LPN did not follow the resident's care plan, which emphasized de-escalation techniques and awareness of the resident's triggers. The LPN admitted to not being aware of the resident's upset state and failed to back away during the altercation, contrary to the expected protocol. The Director of Nursing confirmed that the LPN should have de-escalated the situation and not engaged physically with the resident.
Administrator's Inappropriate Interaction with Resident
Penalty
Summary
The facility failed to maintain the dignity of a resident diagnosed with schizophrenia, psychotic disorder, delusional disorder, and panic disorder. The incident involved the Administrator and the resident, where the Administrator did not use appropriate de-escalation techniques and instead engaged in a playful manner with the resident, who was already upset. The Administrator lightly pushed the resident on the back while escorting them back to their unit, which led to the resident attempting to strike the Administrator. The resident had a history of paranoid delusional behaviors and had been upset due to the confiscation of a lighter and razors by the MDS Coordinator. The resident alleged that the Administrator pushed them and that they were bribed by a Staffing Coordinator with money to not report the incident. However, the investigation found no evidence of abuse or bribery, but it was concluded that the Administrator infringed on the resident's dignity by not handling the situation professionally. Video footage and multiple staff statements corroborated that the Administrator and the resident had a generally good relationship, often engaging in playful interactions. However, during this incident, the Administrator's approach was deemed inappropriate given the resident's escalated state. The Corporate Regional Director acknowledged that the Administrator should have maintained a professional demeanor to uphold the resident's dignity.
Failure to Maintain Adequate Room Temperature
Penalty
Summary
The facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit for two residents, leading to discomfort and potential health risks. On a day when the outside temperature rose to 82.1 degrees Fahrenheit, the temperature in the room shared by Resident #6 and Resident #7 exceeded the maximum allowable limit, reaching 82.1 degrees Fahrenheit. The air conditioning unit in their room was not functioning properly, and the facility did not provide adequate alternative cooling measures, such as additional fans, as outlined in their policy. Resident #6, who has a history of acute pulmonary edema, chronic congestive heart failure, acute respiratory failure, and morbid obesity, reported the excessive heat to staff members, including a social worker and CNAs, but no immediate action was taken to address the issue. The resident also mentioned that their personal fan was broken, and despite informing the staff, it was not replaced promptly. The resident's medical conditions, which include shortness of breath and decreased cardiac output, make maintaining a comfortable room temperature critical for their well-being. Interviews with facility staff revealed that there was a delay in addressing the malfunctioning air conditioning unit. Although the social worker and maintenance worker attempted to adjust the settings and clean the unit, these actions were insufficient to resolve the issue. The maintenance worker did not conduct follow-up temperature checks to ensure the room temperature was within the acceptable range, contributing to the prolonged discomfort experienced by the residents.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). On the evening of the incident, the resident approached a snack cart and engaged in a verbal exchange with the CNA over a bag of chips. The situation escalated when the resident snatched a bag of chips, leading the CNA to forcibly grab and push the resident down the hallway and into a wall. This physical altercation was witnessed by other staff members, including a Hall Monitor and another CNA, who did not intervene. The resident involved in the incident had a complex medical history, including schizophrenia, bipolar disorder, and other mental health conditions. Despite these challenges, the resident was cognitively intact and had been working on managing impulsive behaviors and anxiety with the help of counseling services. The resident's care plan included specific strategies for managing behaviors and mental illness, which the staff were expected to follow. However, during the incident, the CNA failed to utilize these strategies and instead resorted to physical force. The incident was captured on video, showing the CNA's aggressive actions and the lack of intervention from other staff members present. Interviews with the involved parties revealed that the CNA reacted to verbal provocation from the resident by using physical restraint, which was against the facility's policy on abuse and neglect. The facility's Director of Nursing and Administrator expressed disappointment in the staff's handling of the situation, emphasizing that the CNA should have used de-escalation techniques and that physical force was never acceptable.
Failure to Report Abuse Incident Timely
Penalty
Summary
Facility staff, including several CNAs and a Hall Monitor, failed to report an incident of abuse involving a resident and a CNA to the facility Administrator as required by the facility's policy. The incident occurred when a resident, who has multiple psychiatric disorders including schizophrenia and bipolar disorder, was involved in a physical altercation with a CNA over a bag of chips. The CNA was observed shoving and pushing the resident down the hallway and against a wall. Despite witnessing the incident, other staff members did not immediately report it to the Administrator, leading to a delay in the investigation. The incident was captured on video, showing the resident and CNA exchanging words before the physical altercation ensued. Other staff members, including a Hall Monitor and another CNA, observed the incident but did not intervene or report it to the Administrator. One CNA did intervene to separate the resident and the CNA involved in the altercation but only reported the incident to the evening administration later. Interviews with the staff revealed a lack of understanding or adherence to the facility's policy on reporting abuse. Some staff members assumed that the Night Shift Supervisor was aware of the incident and would handle the reporting. The Night Shift Supervisor, however, did not perceive the incident as serious enough to warrant notifying the Administrator, partly due to not having seen the video and the incident being downplayed by those involved.
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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