Cassville Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cassville, Missouri.
- Location
- 1300 County Farm Road, Cassville, Missouri 65625
- CMS Provider Number
- 265460
- Inspections on file
- 25
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 31 (2 serious)
Citation history
Health deficiencies cited at Cassville Health Care Center during CMS and state inspections, most recent first.
Food and beverages served to residents were found not to be consistently palatable, visually attractive, or maintained at a safe and appetizing temperature, as identified during a survey associated with two complaints.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including unclean kitchen surfaces, improper refrigerator temperatures, expired and improperly labeled food, and condiments left unrefrigerated. Staff failed to consistently log refrigerator temperatures and did not follow facility policies for food safety and sanitation, as confirmed by interviews with the Dietary Manager and Administrator.
A persistent fly infestation was observed throughout the facility, with flies present on residents, in their rooms, and in common areas. Multiple residents complained about flies, and some took steps to keep their doors closed. Several pest control devices were found non-functional, and external doors were left ajar or propped open, allowing flies to enter. Staff and residents reported the issue had been ongoing despite visits from a pest control company, and no effective changes were made to address the problem.
Several residents who required staff assistance did not receive showers according to their preferences or the facility's policy, with some going weeks without bathing. Residents and staff reported that the removal of a designated shower aide, unclear shower schedules, and insufficient staffing led to missed showers and unmet hygiene needs. Staff were often unaware of which residents needed showers and when, resulting in resident complaints and discomfort.
A resident with a colostomy, open abdominal wound, and need for ADL assistance did not have a comprehensive care plan addressing these needs. Staff confirmed that care plan meetings had stopped, and only fall risk was documented in the care plan, leaving critical care interventions unaddressed.
A resident with diabetes and a sulfa allergy suffered a foot injury that was not promptly or adequately assessed or treated by staff. Weekly skin assessments were inconsistently documented, a physician-ordered X-ray was delayed for several days, and staff administered a sulfa-containing antibiotic despite the resident's known allergy. The resident's condition worsened, leading to hospitalization for a toe fracture and infection. Staff interviews revealed confusion about responsibilities for wound care and assessment.
The facility did not have a licensed Administrator present or clearly identified, leading to confusion among staff and a lack of oversight. This resulted in insufficient nursing staff, residents not receiving necessary medications, a staff member under investigation for misappropriation returning to work, and an unlicensed driver transporting residents. Staff were unclear about reporting structures, and the absence of leadership contributed to failures in resident care and safety.
A nurse under investigation for misappropriation of funds and diversion of narcotics was allowed to return to work as the only nurse on duty, despite facility policy requiring suspension during such investigations. A resident with multiple chronic conditions, who had previously reported financial exploitation by the nurse, became fearful and considered leaving the facility due to the nurse's return. Staff interviews confirmed that the nurse's presence caused distress among residents and staff, and that established procedures for protecting residents during investigations were not followed.
A resident with chronic pain and a history of kidney disease did not receive prescribed PRN tramadol before dialysis due to LPNs and a CMT lacking access to the medication dispensing system and EMR. Despite reporting severe pain, only acetaminophen was administered, and staff did not notify management or the physician about the inability to provide the ordered medication. Documentation of the resident's pain and actions taken was incomplete, and leadership was unaware of the access issue until after the incident.
The facility did not maintain adequate nursing staff or a working schedule, resulting in nurses and CNAs working excessive hours, periods with only two staff caring for 44 residents, and times when the building was left unattended. This led to residents being left wet and soiled for extended periods and feeling unsafe, with staff and residents expressing concerns about the lack of care and supervision.
The facility allowed two LPNs to work as charge nurses without completing required pre-employment screenings, including criminal background checks, EDL and NA Registry checks, or verifying nursing licenses. Personnel files were not maintained for these staff, and they did not complete applications, orientation, or education prior to working. Staff interviews confirmed that these checks were not performed, and the Administrator was unaware of who authorized the LPNs to work.
The facility did not post the required daily nurse staffing information in a clear and accessible location for residents and visitors. Multiple staff members, including CNAs, RNs, LPNs, and the Business Office Manager, confirmed that the Nurse Staffing Sheet had not been posted or completed for several months, despite facility policy requiring daily updates and postings.
Facility staff did not ensure that two LPNs received the required two-step TB screening prior to working as charge nurses, as required by policy. The facility could not provide personnel files or TB test documentation for these LPNs, and interviews confirmed that they worked on the floor without the necessary screening.
The facility failed to maintain a fully functional call light system, resulting in two residents with significant care needs experiencing long waits for assistance with incontinence. The call system did not provide visual or audible alerts, and staff were not provided with pagers, requiring them to check a monitor at the nurses' station to identify calls. Staff interviews and resident reports confirmed delays in care, with residents left in soiled conditions for extended periods.
A staff member coerced a resident into providing money over several months and failed to repay damages caused by their child. The same staff member also dispensed large quantities of narcotic medication for another resident without a valid order, failed to document administration or destruction, and forged signatures on destruction logs. These actions were discovered through staff interviews, review of financial and medication records, and were not in accordance with facility policy.
Staff failed to follow physician-ordered monitoring parameters when administering medications to two residents with CHF and blood pressure concerns. Medications were given despite vital signs being outside ordered parameters or without checking and documenting required vital signs. Interviews with staff, including a CMT, LPN, DON, and the Administrator, confirmed inconsistent understanding and implementation of monitoring requirements and documentation practices.
Several residents with diabetes did not receive their ordered insulin or have their blood glucose checked because the assigned LPN lacked access to the EMR and medication dispensing system. Residents reported missed doses and staff interviews confirmed the nurse was unable to administer medications due to access issues and a physical limitation. Documentation was incomplete, and there was no care planning for medication management in some cases.
A facility allowed a Transport Driver with a suspended license, due to legal issues including drug paraphernalia possession, to transport multiple residents to physician appointments. Staff interviews and documentation showed that the driver continued to operate the facility's van after the license suspension, and several staff members were aware of the situation before it was formally addressed. The facility lacked a specific policy or job description for the Transport Driver, and there was confusion among staff about licensure requirements.
The facility did not maintain an effective pest control program, as evidenced by repeated and documented sightings of mice and mouse droppings in resident rooms, hallways, and activity areas. Staff and residents reported ongoing pest activity, but the pest control service only addressed the exterior of the building and was unaware of interior issues. The pest log was not reviewed by the pest control technician, and no interior rodent control measures were documented, resulting in continued pest presence.
Staff identified missing narcotic medications affecting three residents and reported the issue to the Administrator, but the facility did not notify DHSS or law enforcement within the required timeframe. Despite facility policy mandating immediate reporting of such allegations, the Administrator, after consulting with regional leadership, chose not to report the incident, resulting in noncompliance with mandatory reporting regulations.
A resident with multiple chronic conditions and moderate cognitive impairment developed a large, painful hematoma on the left lower leg. Staff did not immediately complete a skin assessment, failed to determine the cause of the injury, and delayed obtaining and documenting physician orders for an ultrasound and x-ray. There was inconsistent monitoring and documentation of the injury, and required notifications and follow-up were not properly recorded, contrary to facility policy.
A resident with multiple complex medical conditions received duplicate doses of Trelegy Ellipta due to two active orders for the same medication at different times on the MAR. Staff administered both doses on several days, despite facility policy requiring review and correction of discrepancies. Interviews revealed that LPNs and CMTs noticed the duplicate orders but did not consistently resolve them, and the DON confirmed that only one daily dose should have been given.
A CNA, who was also a nursing student but not licensed or certified as a medication technician, was allowed by the DON and an RN to administer medications and perform blood sugar checks for multiple residents. The CNA prepared and administered medications, scanned CGM systems, and documented readings in the MAR, actions confirmed by interviews with residents and staff. Facility policy and staff statements indicated that only licensed personnel should perform these tasks, but the CNA was permitted to do so without proper credentials or supervision.
A resident with hemiplegia and frequent incontinence was left wet for 30 to 40 minutes on multiple occasions due to staff failing to respond to call lights within the facility's 15-minute policy. Staff interviews confirmed that response times of up to 51 minutes occurred, with delays attributed to non-functional pagers and reliance on visual monitors at the nurses' station. The resident experienced repeated episodes of incontinence and emotional distress as a result.
A resident with severe cognitive impairment and a history of skin issues developed a rash in skin folds, but staff did not document timely application of prescribed Nystatin cream or notify the physician as required by facility policy and the care plan. Interviews confirmed the delay in treatment and lack of documentation, resulting in a deficiency related to failure to provide care according to orders and resident needs.
A resident's right to dignity and respect was violated when two CNAs, following the DON's instructions, entered the resident's room without permission, rearranged items, and discarded personal belongings such as newspapers and meal tray slips. The resident, who was cognitively intact and required significant ADL assistance, was not informed or present during the process and later expressed distress. Multiple staff interviews confirmed that the actions were inappropriate and not in line with facility policy, which requires staff to respect residents' property and obtain consent before handling personal items.
Two residents did not consistently receive prescribed topical medications as ordered, with staff failing to document administration or provide reasons for missed doses. Nursing staff did not always notify the physician or pharmacy when medications were unavailable or not given, and did not consistently follow facility policy for documentation and reporting. The DON and Administrator confirmed that medications were not administered as ordered and that required documentation and notifications were not completed.
The facility failed to maintain sanitation standards in the kitchen, with peeling paint and rust in the microwave posing contamination risks. Additionally, dogs brought by the DON were frequently present in the dining room during meals, against FDA guidelines, causing discomfort among residents and potential health risks.
The facility failed to address and follow up on concerns raised by residents during Resident Council meetings, as documented in meeting minutes from July to September 2024. Issues such as maintenance problems and cleanliness concerns were repeatedly raised without resolution. Interviews revealed that the Activity Director reported issues to morning meetings but did not ensure follow-up, and the Administrator acknowledged the lack of follow-up prior to September 2024.
The facility failed to maintain fire doors, causing mobility issues for residents. Observations showed malfunctioning magnetic hold-open devices, leading staff to prop doors open with chairs. Residents reported difficulties accessing the dining room, and the Maintenance Director acknowledged pending repairs. The Administrator confirmed ongoing issues since April 2024.
The facility failed to conduct necessary pre-employment NA Registry checks for a Dietary Aide, an LPN, and an RN, as required by their abuse prevention policy. This oversight allowed these staff members to begin work and have resident contact without verifying their eligibility to work in a certified LTC facility.
The facility failed to ensure the safety and effectiveness of medications by having expired medications in their carts, affecting at least two residents. An expired Naloxone nasal spray and Nitrostat tablets were found, along with a stock bottle of Geri-kot. The DON attempted periodic checks and audits, but these were not documented, leading to a lapse in medication management.
The facility failed to maintain a clean and comfortable environment, with resident rooms exhibiting floors with wax buildup and a persistent urine smell, and a hallway ceiling showing water damage. Housekeeping and maintenance staff identified issues with cleaning chemicals and delayed repairs, but necessary actions were not completed, compromising the facility's environment.
The facility failed to protect the rights of two residents to have and use their personal possessions during room changes. One resident's belongings were left unsecured in a hallway for two months, while another's items were left in their original room, which was used for storage. Both residents were distressed by the situation, and staff interviews indicated that housekeeping was responsible for moving belongings, but this was not adequately done.
Two residents in a facility with a census of 41 did not receive timely bathing assistance. One resident, with multiple health issues, reported not having a shower since July 2024, except for one instance after family intervention. Another resident, with COPD and diabetes, received infrequent showers, feeling dirty and needing more frequent bathing. Staff interviews revealed issues with shower scheduling and documentation, with CNAs unable to complete showers due to emergencies or staff shortages. The DON acknowledged no audits were conducted to ensure showers were completed.
A facility failed to obtain a physician's order before administering nystatin to a resident with reddened skin and did not timely collect a urine sample for another resident's urinalysis. The first resident, with a history of diabetes and erythema intertrigo, received treatment without an order, while the second resident, showing symptoms like confusion and vomiting, did not have a urine sample collected within the expected timeframe. Staff interviews revealed communication and procedural lapses.
A facility failed to provide adequate dialysis care for a resident with ESRD, resulting in a deficiency due to poor communication with the dialysis center and inconsistent monitoring of fluid intake and dialysis access sites. The resident's care plan included a renal diet and fluid restriction, but staff did not consistently document fluid intake or assess dialysis access sites. Communication between the facility and dialysis center was inconsistent, with reliance on phone calls instead of written forms, leading to a lack of awareness of the resident's laboratory results and dialysis issues.
The facility failed to provide necessary behavioral health services to two residents, one with a history of depression and psychosis and another with multiple sclerosis and depression. Both residents expressed a desire to speak with a psychologist, but the facility did not follow up on these requests. Staff interviews revealed a lack of awareness and procedures for referring residents to psychological services, and there was no psychologist visiting the facility.
The facility exceeded the acceptable medication error rate, reaching 8%, when two residents did not receive their prescribed medications. One resident did not receive pregabalin due to a delay in pharmacy delivery, while another missed a dose of Tylenol 325 mg because it was not in stock. The DON and Administrator indicated that staff should notify them if medications are unavailable, as they might be located elsewhere in the facility or obtained from a local pharmacy.
The facility failed to prevent significant medication errors for two residents. One resident with diabetes did not receive insulin according to physician orders, with nurses administering partial doses without proper documentation or physician notification. Another resident with end-stage renal disease missed multiple doses of medications due to absence and unavailability, with inadequate communication and documentation by staff. The facility's medication administration protocols were not effectively followed, leading to these deficiencies.
Failure to Provide Palatable and Proper-Temperature Food and Drink
Penalty
Summary
The deficiency involves failure to ensure that food and drink provided to residents were palatable, attractive, and maintained at a safe and appetizing temperature. Surveyors identified this concern in connection with complaints #2700845 and #2717249. The cited issues were associated with survey event ID 1D693E-H3, with an exit date of 02/02/26, indicating that during this survey event, observations or findings supported that meals and beverages did not consistently meet required standards for taste, appearance, and temperature.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Surveyors observed multiple deficiencies, including unclean food contact and non-food contact surfaces, improper refrigerator temperatures, improper storage and sealing of food, and failure to discard spoiled or contaminated foods. Specifically, food contact surfaces such as the griddle and oven were found with significant grease and food debris, and storage shelves for pots, pans, and cutting boards contained crumbs and trash. Additionally, condiments requiring refrigeration were left at room temperature on dining tables, and a water cooler tray contained brown-stained water. Refrigeration units throughout the kitchen were found to be operating above the required temperature of 41 degrees Fahrenheit, with recorded temperatures ranging from 46 to 51.9 degrees Fahrenheit. Items such as milk, bologna, cheese, and prepared drinks were stored in these refrigerators, some of which were past their expiration or best-by dates. Staff failed to consistently log refrigerator temperatures as required by facility policy, and some food items were not properly sealed or labeled with accurate dates. The Dietary Manager acknowledged issues with staff compliance regarding cleaning and temperature monitoring protocols. The facility's own policies require food to be stored, thawed, and prepared according to sanitary practices, with all products dated and used or discarded within specified timeframes. However, observations revealed that these policies were not followed, as evidenced by expired food, improper labeling, and inadequate cleaning. The Administrator was unaware if temperature logs were being maintained every shift and could not confirm that all refrigerators were functioning within safe temperature ranges.
Failure to Maintain Effective Pest Control Program Resulting in Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in a persistent and widespread fly infestation throughout multiple areas. Observations revealed flies present in resident rooms, on residents' bodies, bedding, and personal items, as well as in common areas such as the dining room. Several residents reported being bothered by flies, with some taking measures such as keeping their doors closed and posting signs to remind staff to do the same. In one instance, a resident with an open wound had flies buzzing around the affected area, and another resident was observed eating while flies were present in the room. Multiple pest control devices, such as bug lights, were found to be non-functional, with bulbs either burnt out, dim, or replaced with inappropriate types. Key entry points, including external doors, were not properly secured; doors were observed to be ajar or propped open, allowing flies to enter the facility. Staff interviews confirmed that the fly problem had been ongoing for an extended period, with residents and staff both expressing frustration. Staff reported that the pest control company had visited, but the issue persisted, and no changes were made to the pest control treatment plan. Maintenance and administrative staff were aware of the problem, with maintenance attributing the fly entry to a broken courtyard door and residents propping doors open. Despite these known issues, there was no evidence of effective intervention or adjustment to the pest control strategy. The facility's failure to ensure operational pest control devices, secure entryways, and responsive pest management led to continued resident discomfort and a failure to meet the standards outlined in the facility's pest control policy.
Failure to Provide Showers According to Resident Preference and Facility Policy
Penalty
Summary
The facility failed to honor and facilitate resident choice regarding showering for five residents who required staff assistance. Multiple residents, including those with significant physical limitations, cognitive impairments, and at risk for skin issues, did not receive showers according to their preferences or the facility's stated policy. Documentation and interviews revealed that some residents received only one shower in a 30-day period, with gaps of up to three weeks or more between showers, despite expressing a desire for more frequent bathing and reporting discomfort such as itching and feeling unclean. Residents reported that when they requested showers, staff often told them there was not enough time or that there was no designated shower aide available. Staff interviews confirmed that the facility had recently removed the designated shower aide position, leaving CNAs responsible for showers in addition to their other duties. Staff were unclear about which residents needed showers, when showers were last provided, and how to access or use a shower schedule. Several staff members indicated that the workload was too heavy to complete all required showers, and that management had not provided adequate support or clear direction regarding shower scheduling and documentation. The lack of a consistent shower schedule, insufficient staffing, and poor communication among staff led to residents not receiving showers as per their preferences or care plans. Residents and staff both reported frustration with the situation, and the issue was brought to the attention of nursing and administrative leadership. Despite the facility's policy to provide showers per resident request or schedule, the failure to maintain a system for tracking and ensuring showers resulted in unmet hygiene needs for multiple residents.
Failure to Develop Comprehensive Care Plan for Resident with Colostomy and Wound
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan for a resident with significant medical needs, including a colostomy, an open abdominal wound, and requirements for assistance with activities of daily living (ADLs). The only care plan in place addressed fall risk, with interventions limited to therapy referrals. No care plan interventions were documented for the resident’s colostomy care, wound management, or ADL support, despite these needs being clearly identified in the resident’s Minimum Data Set (MDS) and through direct observation. Observations revealed that the resident had a colostomy bag with feces present and an open abdominal wound with thick, yellow drainage, both of which were not addressed in the care plan. The resident reported that their abdominal bandage needed changing, and staff confirmed that care plans should include such interventions. Multiple staff interviews indicated that care plan meetings had ceased several months prior due to the former DON’s refusal to participate, resulting in care plans not being updated or developed for residents with new or ongoing needs. Staff, including the Social Service Director, LPN, and CMT, acknowledged that care plans were incomplete and not reflective of residents’ current care requirements. The Administrator and Senior Director of Regulatory Affairs confirmed that care plan meetings were not being held and that there was no clinical staff available to participate in the process. As a result, the resident’s care needs for colostomy management, wound care, and ADL assistance were not addressed in the care planning process.
Failure to Timely Assess, Treat, and Document Resident's Foot Injury and Allergy
Penalty
Summary
Facility staff failed to provide timely and adequate assessment and treatment for a resident who sustained a toe and skin injury. The resident, who had a history of chronic kidney disease, diabetes, and allergies to sulfa antibiotics, reported that their right foot was run over by another resident in a wheelchair. Despite physician orders for weekly skin assessments, documentation showed that these assessments were not consistently completed, with only one assessment documented in the month following the injury. Progress notes also lacked documentation of skin assessments during the critical period after the injury. When the resident reported pain and swelling in the right foot, staff contacted the physician and received a verbal order for a mobile X-ray. However, the X-ray was not obtained until four days after the order was placed, despite repeated requests from the resident and their family. During this period, the resident's condition worsened, with increased swelling, redness, and the development of an open, necrotic area on the toe. Staff interviews revealed confusion about responsibility for wound and skin assessments, and delays in both assessment and treatment were noted. Additionally, staff administered Bactrim DS, an antibiotic containing sulfa, to the resident despite a documented allergy to sulfa antibiotics. The medication was given on multiple occasions before being held after the resident's family raised concerns. The resident ultimately required hospitalization for evaluation and treatment of the foot injury, which was later diagnosed as a toe fracture with infection. Throughout the incident, there were multiple failures in timely assessment, documentation, communication, and adherence to physician orders and resident-specific allergies.
Failure to Maintain Licensed Administrator and Oversight Resulting in Lapses in Care and Safety
Penalty
Summary
The facility failed to ensure a licensed Administrator was available and actively involved in daily operations, resulting in significant lapses in care and oversight. The Administrator position was filled by an individual who did not possess a Missouri Administrator license, and there was confusion among staff regarding who the Administrator was. Staff were unable to identify the current Administrator, and the individual serving as Administrator was unaware of key events, such as ongoing investigations into misappropriation. The facility did not have a policy related to the Administrator role, and there was no Temporary Emergency Administrator License issued. Due to the lack of effective administrative oversight, the facility did not maintain sufficient nursing staff to meet resident needs, leading to residents being left wet for extended periods and nurses working excessive shifts. Staff did not have access to necessary medications, including insulin and pain medications, resulting in residents not receiving ordered treatments. Additionally, a staff member under investigation for misappropriation was allowed to return to work, causing at least one resident to feel unsafe and consider leaving the facility. The facility also allowed an unlicensed driver to transport residents to appointments, as there was no Administrator available to address the issue when it was discovered. Interviews with staff, including the Business Office Manager, LPNs, and the Medical Director, confirmed the absence of a licensed Administrator and the resulting confusion and lack of leadership. Staff were unclear about reporting structures and who to contact in the event of issues, such as the discovery of a suspended driver's license. The lack of administrative presence and oversight directly contributed to failures in resident care, medication administration, staffing, and resident safety.
Failure to Protect Resident During Investigation of Staff Misappropriation
Penalty
Summary
The facility failed to protect residents from potential abuse, neglect, exploitation, or mistreatment during an ongoing investigation of misappropriation involving a registered nurse (RN). Despite the facility's policy requiring immediate suspension and removal of any staff member accused of mistreatment pending investigation, the RN under investigation for both diversion of narcotics and misappropriation of resident funds was allowed to return to work as the only nurse on duty. This action was taken after the facility owner personally contacted the RN and requested their return, despite the ongoing investigation and the RN's prior termination for substantiated allegations. A resident with chronic obstructive pulmonary disorder, congestive heart failure, and an irregular heartbeat, who was cognitively intact, reported that the RN had solicited and received money from them on multiple occasions, both in cash and through a mobile payment app. The resident also reported that the RN's child broke their tablet. The resident only felt safe to report the financial exploitation after the RN was initially suspended. However, when the RN returned to the facility, the resident experienced significant fear and mental anguish, packed their belongings, and considered leaving the facility due to fear of retaliation. The RN attempted to contact and speak with the resident after returning to work, further exacerbating the resident's distress. Multiple staff members, including nurses and certified nurse aides, expressed concern and stated that the RN should not have been allowed to return to the facility while under investigation. Staff interviews confirmed that the RN was the only nurse on duty during their return and that the resident was visibly upset and fearful. The facility's own policies and staff statements indicated that accused employees should be suspended and removed from resident care areas pending investigation, but these procedures were not followed, resulting in the resident not being protected from further potential harm.
Failure to Provide Timely Pain Management Due to Medication Access Issues
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with chronic kidney disease, low blood pressure, and heart disease, who required pain control, particularly before dialysis treatments. The resident had physician orders for both scheduled pain assessments and as-needed (PRN) analgesics, including acetaminophen and tramadol. Despite these orders, staff did not administer the prescribed tramadol prior to dialysis, even when the resident reported severe pain rated at 8 out of 10. Instead, only acetaminophen was given, which the resident stated was less effective. Documentation showed that staff did not record the reasons for not administering tramadol, nor did they notify the physician or management about the inability to access the medication. Multiple interviews revealed that several LPNs and a Certified Medication Tech (CMT) were unable to access the medication dispensing system or the electronic medical records (EMR) due to lack of system access, especially for staff who did not regularly work at the facility. As a result, they could not administer PRN pain medications, including tramadol, as ordered. Staff were aware of the resident's pain and the usual practice of administering tramadol before dialysis, but were unable to fulfill this due to access issues. The resident repeatedly reported severe pain and distress, both verbally and through nonverbal cues, over the course of two days. Facility leadership, including the Social Services Director, Medical Director, and Administrator, confirmed that nurses should have had access to the medication dispensing system prior to starting their shifts. However, the Administrator was not aware of the access issues until after the events occurred. Staff interviews indicated that, in the absence of access, they did not escalate the issue to management or the physician in a timely manner, nor did they document the lack of access or the resident's ongoing pain in the medical record. This resulted in the resident not receiving prescribed pain management consistent with professional standards of practice and the resident's care plan.
Failure to Maintain Sufficient Nursing Staff and Scheduling
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, resulting in significant lapses in care and resident safety. Multiple interviews and record reviews revealed that the facility did not provide any working nursing staffing sheets or schedules when requested, and staff reported that no one was actively making the schedule. Staff were left to call each other for coverage, and there was no consistent use of agency staff despite a contract being in place. On several occasions, nurses and CNAs worked for over 30 consecutive hours without relief, and at one point, the building was left with only two staff members to care for 44 residents overnight. There were also periods when the building was left unattended for short durations. Staff interviews indicated that the lack of adequate staffing led to residents being left wet and soiled for extended periods, with some residents not being changed since early morning hours. Residents expressed concerns for their safety and well-being, reporting that they were unable to get assistance when needed and felt unsafe due to the absence of staff. The police were called to the facility after residents made multiple calls regarding their safety, and the police subsequently contacted the Department of Health and Senior Services. Staff also reported that the facility had not maintained staffing sheets for a long time, and the only time a staffing sheet was seen was during a state complaint investigation. The deficiency was further corroborated by statements from the facility's medical director and physician, who both indicated that two staff members were not sufficient to care for the resident census and that they expected the facility to have a working schedule and staffing sheet. The business office manager and other staff confirmed that the facility only had two nurses employed at the time and that the lack of a schedule had persisted for weeks. The administrator acknowledged the staffing shortages and the inappropriateness of leaving only one staff member in the building, as well as the absence of a working schedule prior to their arrival.
Failure to Complete Pre-Employment Screening and License Verification for Nursing Staff
Penalty
Summary
The facility failed to implement and follow its own policies and procedures designed to prevent abuse, neglect, and exploitation of residents by not completing required pre-employment screenings for two Licensed Practical Nurses (LPNs) before they began working with residents. Specifically, the facility did not conduct Criminal Background Checks (CBC), Employee Disqualification List (EDL) checks, Nurse Aide (NA) Registry checks, or verify nursing licenses for these staff members prior to their shifts. The facility also did not have personnel files for these LPNs, and there was no evidence that they completed employment applications, orientation, or required education before working. Interviews with staff and the Business Office Manager confirmed that the necessary background and licensure checks were not performed for the two LPNs. The LPNs themselves stated that they were not subjected to the required screenings or onboarding processes before working their shifts, and one LPN indicated they had not worked at the facility since earlier in the year. Observations confirmed that both LPNs worked as charge nurses without the facility having completed the mandated checks or maintaining their personnel files. Further interviews with other staff, including a Certified Medication Technician and the Medical Director, reinforced that the facility's standard practice was to complete all background and registry checks before allowing new staff to work with residents. The Administrator acknowledged that the required checks were not completed for the two LPNs and was unaware of who authorized them to work. The failure to follow established policies and procedures resulted in staff working with residents without proper vetting, as required by facility policy and regulatory standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors, as required by its own policy. Multiple observations over several days confirmed that the Nurse Staffing Sheet was not displayed in the entry hall, at the nurses' station, or by the time clock. Staff interviews revealed that several employees, including CNAs, RNs, and LPNs, were unaware of the location of the Nurse Staffing Sheet or reported that it had not been posted for several months. The former DON, who was responsible for posting the sheet, admitted to not having posted it for at least four months. Further interviews with other staff, including the Business Office Manager and the Administrator, confirmed that the Nurse Staffing Sheet had not been completed or posted for an extended period, and no copies were available for review. The facility's policy required daily posting of the staffing sheet, including up-to-date information on licensed and unlicensed nursing staff, but this was not followed, resulting in a lack of accessible staffing information for residents and visitors.
Failure to Ensure Timely TB Screening for Staff
Penalty
Summary
Facility staff failed to fully implement their infection prevention and control program by not ensuring that two LPNs received the required two-step tuberculosis (TB) screening test prior to working on the floor, as mandated by facility policy. The policy required all new employees to receive a two-step PPD skin test upon hire and an annual one-step TB test thereafter, with documentation kept in employee files. However, the facility was unable to provide personnel files or TB test documentation for the two LPNs in question. One LPN confirmed during interview that they had worked on the floor without a TB test, and the Business Office Manager stated that neither LPN was an employee of the corporation or a staffing agency, and no TB test records were available for them. Multiple staff interviews, including with the facility physician and Medical Director, confirmed that staff should have a negative TB test prior to working with residents. The Administrator acknowledged that staff should have their first TB skin test read before working on the floor but was unaware of who authorized the LPNs to work or their employment status. Both LPNs worked as charge nurses without the required TB screening, and the facility census at the time was 44.
Failure to Maintain Functional Call Light System Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide a fully functional call light system for residents, as required by policy and state regulations. The call light system did not illuminate outside resident rooms or make an audible sound when activated, and staff were not provided with pagers to receive notifications of call lights. Instead, staff had to physically check a monitor at the nurses' station to determine if any call lights were on, which led to significant delays in response times, especially for staff assigned to areas distant from the nurses' station. The facility's previous exception to use a wireless call system with pagers had expired, and the required pagers were not available or functional for an extended period. Two residents were directly affected by these deficiencies. One resident, with diagnoses including COPD, stroke, diabetes, depression, and anxiety, required assistance with activities of daily living and was frequently incontinent. This resident reported waiting 15 to 30 minutes, and sometimes up to an hour, for staff to respond to call lights at night, resulting in urinating in bed and experiencing skin discomfort and embarrassment. Another resident, with chronic respiratory failure, depression, anxiety, and diabetes, also required substantial assistance and was frequently incontinent. This resident reported waiting up to an hour for staff to respond, resulting in having to lie in feces, which caused feelings of indignity and anger. Staff interviews confirmed the lack of functional pagers and the absence of visual or audible alerts from the call light system. Staff described the need to walk to the nurses' station to check for call lights, with some reporting that pagers had not been available for months and that residents had complained about delayed responses. Observations by surveyors corroborated that the call light system did not function as intended, with no lights or sounds activating when tested in resident rooms.
Misappropriation of Resident Funds and Controlled Substances by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, specifically the former DON/RN, engaged in misappropriation of resident property and funds. One resident, who was cognitively intact and had diagnoses including COPD and CHF, reported that the DON/RN repeatedly requested and received money from them over several months. The staff member was aware of the resident's financial situation and coerced the resident into providing funds, both in cash and through a mobile payment app. The resident also reported that the staff member's child broke their tablet, and the staff member promised repayment, which did not occur. The resident only felt safe to report the incident after the staff member was suspended for a separate issue. Another deficiency involved the same staff member's handling of controlled substances for a different resident with severe cognitive impairment and diagnoses including dementia and Alzheimer's disease. The staff member dispensed significant quantities of hydrocodone/acetaminophen from the medication dispensing system for this resident, despite the absence of a corresponding physician order in the resident's medical record or medication administration record. There was no documentation of administration or proper destruction of these narcotics, and destruction logs were either missing or contained forged signatures. The staff member claimed to have destroyed the medications but failed to follow required documentation procedures and did not ensure a second nurse was present for destruction, as required by policy. Interviews with other staff confirmed that the staff member's actions were not in line with facility policy or standard practice. The discrepancies in medication dispensing and lack of proper documentation were discovered by other nurses, who reported the findings to administration. The staff member was found to have forged signatures and failed to document communications with the pharmacy or physician regarding the medication orders. The deficiencies were substantiated through review of witness statements, bank records, medication dispensing logs, and interviews.
Failure to Follow Physician-Ordered Monitoring Parameters During Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not following physician-ordered monitoring parameters during medication administration. For one resident with diagnoses of congestive heart failure (CHF) and high blood pressure, staff administered metoprolol tartrate despite physician orders to hold the medication if the resident’s systolic blood pressure was 110 mm/Hg or less or if the heart rate was below 65 beats per minute. Documentation showed that the medication was given multiple times when the resident’s heart rate was below the ordered threshold, with recorded heart rates as low as 42 beats per minute. Another resident with CHF and orthostatic hypotension had a physician order for Entresto, with instructions to hold the medication if the standing systolic blood pressure was less than 100 mm/Hg. Staff administered this medication twice daily over a period of several weeks without consistently checking or documenting the resident’s blood pressure prior to administration, as required by the order. The vital sign summary indicated that blood pressure was only recorded once during this period, and staff interviews confirmed a lack of awareness and compliance with the monitoring requirements. Interviews with facility staff, including a Certified Medication Technician, an LPN, the Director of Nursing, and the Administrator, revealed inconsistent understanding and implementation of the policy regarding medication administration with vital sign parameters. Staff acknowledged that vital signs should be checked and documented on the medication administration record (MAR) when required by physician orders, but there was no designated place on the MAR for this documentation, and the required monitoring was not consistently performed.
Failure to Administer Insulin Due to Lack of Staff Access
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors when staff did not administer insulin as ordered for three residents with diabetes. The residents had physician orders for specific types and dosages of insulin, including scheduled and sliding scale doses, as well as orders for regular blood glucose monitoring. On the morning in question, documentation showed that blood sugar checks and insulin administrations were not completed or recorded for these residents. Progress notes did not provide explanations for the missed doses, and residents reported not receiving their insulin or having their blood sugar checked. Interviews with the affected residents revealed that they were aware of the missed insulin doses and expressed concern about their blood sugar levels. One resident was observed to be flushed and worried, another reported not receiving insulin or having blood sugar checked, and a third appeared fatigued and unable to hold a conversation. All three residents stated that staff informed them the nurse on duty did not have access to administer insulin or check blood sugar levels. The Medication Administration Records (MARs) and progress notes corroborated the lack of documentation and administration for the scheduled insulin doses and blood glucose checks. Staff interviews confirmed that the nurse assigned to administer medications that morning did not have access to the electronic medical records (EMR) or the medication dispensing system, and was therefore unable to provide the required insulin. The nurse also reported having a broken hand, further limiting their ability to administer medications. Other staff members and facility leadership acknowledged that access to the medication system should have been provided prior to the start of the shift, and that residents should receive medications as ordered. The deficiency was further substantiated by the lack of care planning for medication management in some residents' records and the absence of communication to the physician regarding missed doses.
Unlicensed Transport Driver Provided Resident Transportation
Penalty
Summary
The facility failed to comply with Federal, State, and local laws and professional standards by allowing a Transport Driver with a suspended driver's license to transport four residents to physician appointments. Documentation and interviews revealed that the Transport Driver's license was suspended due to legal issues, including charges for driving while license suspended/revoked and unlawful possession of drug paraphernalia. Despite the facility's policy requiring verification and maintenance of valid licensure for personnel, the Transport Driver continued to operate the facility's van and transport residents on multiple occasions after the suspension of their license. Staff interviews indicated that several employees, including a CNA, NA, and the Business Office Manager, were aware of the Transport Driver's suspended license, with some learning about it through direct communication or by checking online records. The Business Office Manager confirmed that the driver continued to transport residents until the issue was brought to their attention by other staff. The facility did not provide a policy or job description specific to the Transport Driver, and there was confusion among staff regarding the licensure requirements for operating the facility's van. The Medical Director stated that it would not be expected for anyone with a suspended license to serve as the transport driver.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in multiple reported and observed sightings of mice and mouse droppings in various areas, including resident rooms and common areas. The pest control policy required a written agreement with an outside pest service for regular and comprehensive pest control, including both interior and exterior measures, and a system for reporting and addressing pest issues between scheduled visits. Despite this, the pest control service only provided rodent control measures for the exterior of the facility, and no interior rodent pest control actions were documented, even after repeated reports of mice inside the building. Staff and residents reported frequent sightings of mice and mouse droppings in resident rooms, hallways, and activity areas over a period of several weeks. Specific observations included mouse droppings in residents' clothing drawers and closets, mice running in hallways and rooms, and mice jumping out of a resident's wardrobe drawer. Staff consistently documented these sightings in a pest log, but the pest control technician was unaware of these reports and had not reviewed or signed the logbook. Residents and staff reported that traps placed in rooms were ineffective, and the issue persisted nightly, particularly in the back hall and specific resident rooms. Interviews with staff, including housekeepers, CNAs, and the DON, confirmed ongoing pest activity and a lack of effective response. The pest control technician stated that he was only responsible for exterior rodent control and was not made aware of interior pest issues until the surveyor's inquiry. The administrator was unsure if the pest control company reviewed the pest logbook and acknowledged that the company had not signed it. The facility's failure to coordinate and implement interior pest control measures, despite ongoing reports and documentation of pest activity, led to the uncorrected deficiency.
Failure to Timely Report Medication Misappropriation Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of medications to the Department of Health and Senior Services (DHSS) and law enforcement within the required twenty-four hour timeframe. Staff discovered missing narcotic medications for three residents and reported the issue to the Administrator. The facility's policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation to the appropriate agencies, including the state agency, within prescribed timeframes. Despite this, documentation showed that the facility did not notify DHSS regarding the misappropriation allegation. The investigation revealed that a possible diversion of medications was identified when staff noticed unaccounted-for narcotic medications and discrepancies in the medication dispensing records. Specifically, more hydrocodone/acetaminophen tablets were dispensed than ordered, and destruction logs provided by the implicated nurse appeared altered. The nurse in question was suspended pending investigation, but there was no evidence that the incident was reported to DHSS as required by policy and regulation. Interviews with various staff members, including LPNs, CNAs, and CMTs, indicated that they understood the requirement to report allegations of misappropriation to the Administrator and that the Administrator was responsible for reporting to DHSS within two hours. However, the former Administrator stated that after consulting with regional leadership, it was decided not to report the incident to DHSS, resulting in a failure to comply with mandatory reporting requirements.
Failure to Monitor, Assess, and Document Bruising and Delayed Diagnostic Orders
Penalty
Summary
Facility staff failed to provide care according to standards of practice for a resident with multiple diagnoses, including congestive heart failure, high blood pressure, expressive aphasia, and depression. The resident, who had moderate cognitive impairment and was independent with activities of daily living, reported a large, painful bruise on the left lower leg. The nurse observed a significant hematoma and bruising but did not immediately determine the cause, question staff about possible injury or falls, or complete a skin assessment at the time of discovery. The nurse notified the DON, physician, and family, but there was a delay in obtaining and documenting physician orders for diagnostic tests. Physician orders for an extremity ultrasound and a tibia/fibula x-ray were not obtained until three days after the bruise was discovered. There was also a delay in completing the ordered tests due to an error in the order and equipment brought by the technician. Staff failed to document the process and results related to the ultrasound and x-ray in the resident's progress notes. Additionally, there was no documentation of a fall on the date the bruise was discovered, and staff did not consistently monitor or document the resident's condition or the status of the bruise in subsequent progress notes and skin assessments. Interviews with nursing staff and the DON confirmed that the nurse should have completed a skin assessment upon discovery of the bruise, monitored the bruise every shift, and documented all notifications and results. The DON was unaware of the delay in entering the diagnostic orders and noted that the nurse incorrectly documented a fall. The facility's policy required prompt notification and documentation of changes in condition, but these procedures were not followed, resulting in a lack of timely assessment, monitoring, and documentation for the resident's injury.
Duplicate Medication Orders Result in Administration Errors
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration systems, resulting in a resident receiving duplicate doses of Trelegy Ellipta, an inhaled medication intended for once-daily use. Staff entered two separate orders for the same medication for the same resident, one at 7:00 A.M. and another at 9:00 A.M., and subsequently administered both doses on multiple days as documented in the Medication Administration Record (MAR). The facility's policy required staff to review the MAR, administer medications as ordered, and correct any discrepancies, but these procedures were not followed. The resident involved had significant medical conditions, including stage 4 kidney disease, general anxiety disorder, major depression, hypertension, blindness in one eye, and impaired thought processes related to metabolic encephalopathy. The care plan specified that staff should administer medications as ordered and monitor for side effects and effectiveness. Despite this, the MAR contained duplicate orders for Trelegy Ellipta, and staff administered the medication twice daily on several occasions, contrary to the physician's order for once-daily administration. Interviews with staff revealed that both LPNs and Certified Medication Technicians were aware of duplicate orders appearing on MARs but did not consistently take action to resolve the issue. Some staff attempted to discontinue extra orders when errors were found, while others were unsure why duplicate orders existed. The Director of Nursing confirmed that only one dose per day should have been administered and that staff should have recognized and reported the duplicate order. The administrator stated that nursing should verify that the MAR matches the prescription before administering medication.
Unlicensed Personnel Administered Medications and Performed Blood Sugar Checks
Penalty
Summary
The facility failed to ensure that only appropriately licensed personnel administered medications and performed blood sugar checks for residents. According to the facility's own policy, only individuals licensed or permitted by the state are allowed to prepare, administer, and document medication administration. However, a certified nurse aide (CNA), who was also a nursing student but not yet licensed or certified as a medication technician, was permitted by the Director of Nursing (DON) to administer medications and perform blood sugar checks for multiple residents. The CNA was observed by residents and staff administering medications and conducting blood glucose monitoring without direct supervision in resident rooms. Interviews revealed that the DON called the CNA to the facility specifically to allow the CNA to practice medication administration and blood sugar checks, despite the CNA not having completed the required clinical check-offs or holding the necessary certification. The DON and a registered nurse (RN) prepared medications and provided them to the CNA, who then administered them to residents. The DON initially observed and assisted the CNA but later left the facility, leaving the RN to oversee the CNA. The CNA administered medications to 22 residents and performed blood sugar checks on three residents during a single shift, including scanning continuous glucose monitoring (CGM) systems and documenting readings in the medication administration record (MAR). Other staff, including a certified medication technician (CMT), LPN, and RN, confirmed that medication administration and blood sugar checks were not within a CNA's scope of practice and that only nurses or CMTs should perform these tasks. The administrator also acknowledged that CNAs should not administer medications or perform blood sugar checks or CGM scans. The facility's failure to adhere to its own policy and state regulations resulted in unlicensed personnel administering medications and performing clinical tasks reserved for licensed staff.
Failure to Respond Timely to Call Light Results in Prolonged Incontinence Episode
Penalty
Summary
A deficiency occurred when staff failed to respond to a resident's call light in a timely manner, resulting in the resident being left wet for an extended period. The facility's policy required staff to respond to all call lights within 15 minutes, with incontinence needs considered high-priority. However, documented call light response times for the resident ranged from approximately 28 to 51 minutes over several days, far exceeding the facility's policy and expectations. Multiple staff interviews confirmed that these response times were not appropriate and that staff should not wait 30 minutes or longer to answer a call light. The resident involved had significant medical needs, including a history of stroke with right-sided hemiplegia, frequent urinary incontinence, and dependence on staff for toileting and personal hygiene. The resident was cognitively intact and able to communicate needs, activating the call light before needing to use the restroom. Despite this, the resident reported being left wet for 30 to 40 minutes while waiting for assistance, leading to episodes of incontinence and emotional distress. The resident also filed a grievance regarding the delayed call light response, stating that the issue persisted and had not been addressed. Staff interviews revealed that the call light system relied on visual monitors at the nurses' station, and pagers intended to alert staff were not operational or missing. Staff acknowledged that any team member could answer a call light, but delays were common, especially during shift changes or when staffing was low. The charge nurse and DON were identified as responsible for ensuring timely responses, but the lack of functional pagers and inconsistent monitoring contributed to the prolonged response times experienced by the resident.
Failure to Timely Treat and Document Skin Rash in Resident
Penalty
Summary
Staff failed to provide timely treatment and care for a resident who developed a rash, as required by facility policy and the resident's care plan. The resident, who had diagnoses including dementia, schizophrenia, and anxiety, was identified as being at risk for impaired skin integrity and had a history of moisture-associated skin damage in the abdominal folds. Weekly skin observation tools documented redness and yeast under the resident's breasts and abdominal folds, but there was no documentation of physician notification or timely application of prescribed Nystatin cream during multiple periods when the rash was observed. The resident's care plan required weekly skin assessments, physician notification of new skin impairments, and implementation of treatment orders. Despite this, staff did not document applying the as-needed Nystatin cream to the affected areas from the time the rash was first observed until several weeks later. Additionally, there was no documentation in the progress notes explaining why the treatment was not administered, nor was there evidence that the physician was notified of the change in the resident's skin condition during this period. Interviews with staff, including an LPN and the DON, confirmed that the resident frequently developed yeast rashes and had an as-needed order for Nystatin cream, which later became a scheduled treatment. However, the DON was unaware of the delay in treatment, and the Administrator stated that staff should assess, document, and notify the physician when new skin issues are identified. The lack of timely treatment and documentation constituted a failure to follow facility policy and the resident's care plan.
Failure to Honor Resident's Right to Dignity and Personal Possessions
Penalty
Summary
Two certified nursing assistants (CNAs) entered a resident's room without the resident's knowledge or permission and proceeded to rearrange items and remove personal belongings. The CNAs discarded newspapers, meal tray slips, and possibly magazines, and moved the resident's food to a different location. The resident, who was cognitively intact but required significant assistance with activities of daily living, was not present during this process and was not informed beforehand. The resident later expressed distress, stating that the items removed were important and that staff should have sought permission before handling personal property. Interviews with the involved CNAs confirmed that they did not ask the resident for permission before rearranging the room or discarding items. The CNAs stated they were acting on instructions from the Director of Nursing (DON), who cited safety and fire hazard concerns. However, both CNAs acknowledged that it was inappropriate to remove or rearrange a resident's belongings without consent, recognizing that the resident's room is their home and their property should be respected. Other staff members, including additional CNAs, a certified medication technician, an LPN, the business office manager, the social services director, and the housekeeping supervisor, all agreed that the actions taken did not treat the resident with dignity and respect, and that staff should not handle residents' belongings without their knowledge or permission. The DON admitted to instructing the CNAs to remove newspapers and acknowledged that permission from the resident was not obtained. The DON, along with the administrator and other staff, agreed that the resident was not treated with dignity and respect, and that the resident's right to retain and use personal possessions was not honored. Facility policies reviewed during the investigation emphasized the importance of treating residents with dignity and respect, including respecting their private space and property, and ensuring residents are informed and procedures are explained before being performed.
Failure to Accurately Administer and Document Topical Medications
Penalty
Summary
The facility failed to ensure accurate administration and documentation of topical medications as ordered by physicians for two residents. For one resident with diagnoses including COPD, asthma, and diabetes, there were multiple instances where triamcinolone acetonide cream was not documented as administered on both day and evening shifts, with some entries lacking reasons for missed doses or simply noting the resident was sleeping. The resident's care plan required medication administration per physician's orders and reporting of any adverse effects, but the medication administration records (MAR) and progress notes showed repeated omissions and insufficient documentation. Another resident, with severe cognitive impairment and a history of diabetes and bullous pemphigoid, also experienced missed and undocumented doses of both triamcinolone and clobetasol creams. Orders required these topical medications to be applied twice daily to specific areas, but the MAR and progress notes revealed several days where applications were not documented, reasons were not provided, or the medication was noted as unavailable. Staff interviews confirmed that nurses were responsible for applying these medicated creams and that any missed doses or unavailable medications should have been documented, with the physician and pharmacy notified as per facility policy. Interviews with the DON and Administrator confirmed that the residents did not receive their medications as ordered and that staff failed to document reasons for missed doses or notify appropriate parties. The DON also identified issues with staff not properly checking both the MAR and TAR for medication orders, contributing to the missed applications. Facility policy required immediate reporting and documentation of any discrepancies in medication administration, which was not consistently followed in these cases.
Sanitation and Animal Control Deficiencies in Dining and Kitchen Areas
Penalty
Summary
The facility failed to maintain proper sanitation and safety standards in the kitchen, leading to potential food contamination. Observations revealed a significant area of peeling paint on the ceiling above the food preparation table, which had been in that condition since at least June 2024. Additionally, a gap was noted between a repair material and the ceiling, and the microwave had a discolored and rusted area due to peeling paint. Interviews with staff, including a Dietary Aide and the Dietary Manager, confirmed awareness of these issues, but they had not been addressed, posing a risk of contamination to food being prepared. Furthermore, the facility allowed dogs in the dining room during meal times, which is against the FDA Food Code 2022 due to the risk of disease transmission from animals. The Director of Nursing (DON) regularly brought two dogs to the facility, and these dogs were observed in the dining room during resident meals. Residents expressed discomfort with the presence of dogs during meals, and staff confirmed that the dogs occasionally urinated and defecated in the facility, including the dining room. Interviews with various staff members, including the Dietary Manager and the Housekeeping Supervisor, indicated that the presence of dogs in the dining room was a known issue. Despite attempts to keep the dogs out, they frequently entered the dining area during meal times. The Administrator acknowledged that the dogs should not be in the dining room during meals, but the issue persisted, contributing to the deficiency in maintaining a safe and sanitary dining environment.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to provide a fully functioning Resident Council Group by not addressing and providing feedback on concerns expressed by residents during council meetings. The facility's policy supports residents' rights to organize and participate in the Resident Council, which serves as a forum for residents to voice concerns and suggestions for improvement. However, the review of Resident Council Meeting Minutes from July to September 2024 revealed that various issues raised by residents, such as missing personal items, maintenance problems, and cleanliness concerns, were not documented as resolved or followed up on in subsequent meetings. Interviews with residents and staff further highlighted the lack of follow-up on issues raised during council meetings. Residents expressed frustration that their concerns, such as broken doors and spider webs, were not addressed over several months. The Activity Director admitted to taking notes and reporting issues to morning meetings but acknowledged that there was no additional follow-up or resolution of the concerns. The Administrator confirmed that prior to September 2024, there was no follow-up on issues from previous months, and staff were expected to address concerns but failed to report back to the Resident Council.
Failure to Maintain Fire Doors Causes Resident Mobility Issues
Penalty
Summary
The facility failed to maintain the fire doors, resulting in difficulties for residents moving about the facility. Observations during the survey period revealed that the smoke barrier doors were not functioning properly, with magnetic hold-open devices failing to operate as intended. This issue was noted on the 200 hall, where a smoke door was held open due to a sticky or warped floor. Residents reported that the magnetic hold-open devices had been non-functional since July 2024, leading staff to prop open the doors with chairs. This situation was documented in Resident Council Meeting Minutes from July and August 2024, where residents expressed concerns about the fire/smoke doors being closed and not working. Several residents, including those with mobility challenges, reported difficulties in accessing the dining room due to the malfunctioning doors. Interviews with residents and staff confirmed that the doors had been propped open with chairs, and some residents had to wait for assistance to pass through the smoke barrier doors. The Maintenance Director acknowledged the issues with the magnetic holders and stated that repairs were pending. The Administrator confirmed that the problem had been ongoing since April 2024 and that an in-service was conducted to address the issue of doors being propped open. However, the Administrator was unaware of specific issues with the Cardinal hall smoke doors.
Failure to Conduct Pre-Employment NA Registry Checks
Penalty
Summary
The facility failed to fully implement its abuse prevention policy by not conducting necessary pre-employment checks on three staff members before they began working and having contact with residents. Specifically, the facility did not perform a Nurse Aide (NA) Registry check, which is crucial to ensure that potential employees do not have a history of abuse, neglect, or misappropriation of property that would disqualify them from working in a certified long-term care facility. This oversight affected a Dietary Aide, a Licensed Practical Nurse, and a Registered Nurse, all of whom were hired without the required registry checks. During interviews, the Business Office Manager admitted to not conducting the NA Registry check for the Dietary Aide because it was their first job, and acknowledged that the checks for the LPN and RN were overlooked. The Administrator confirmed that it was expected for staff to check the NA Registry for all new employees to ensure no federal indicators were present. The facility's policy clearly outlined the necessity of these checks as part of the pre-employment screening process, which includes criminal history, background, and misconduct registry checks.
Expired Medications Found in Facility's Medication Carts
Penalty
Summary
The facility failed to ensure the safety and effectiveness of physician-ordered medications by having expired medications in their medication carts, affecting at least two residents. During an observation, it was found that the facility had an expired box of Naloxone nasal spray, used for treating narcotic overdose, with a manufacturer's expiration date of June 2024, intended for one resident. Additionally, an expired bottle of Nitrostat sublingual tablets, used for treating chest pain, with an expiration date of February 2024, was found in the nurse medication cart for another resident. Furthermore, a stock bottle of Geri-kot, used to treat constipation, with an expiration date of March 2024, was also found in the medication cart. Interviews with the Director of Nursing (DON) revealed that there was an attempt to periodically check the medication carts and medication room for expired medications. The DON mentioned that audits of the medication room were conducted every two weeks, and night nurses were supposed to start auditing the medication carts for expired medications in September 2024, but these audits were not documented. The DON also suspected that the expired Naloxone might have been mistakenly left on the crash cart and not returned to the pharmacy for replacement, indicating a lapse in the medication management process.
Environmental Deficiencies in Resident Rooms and Hallway
Penalty
Summary
The facility failed to maintain a functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the condition of the floors and ceilings. Observations revealed that several resident rooms had floors with a buildup of a black, gummy substance, chipped tiles, and a tacky texture due to wax buildup. The floors were not cleanable, and there was a persistent urine smell in some rooms. Interviews with housekeeping staff indicated that the cleaning chemicals used were ineffective and contributed to the wax buildup, making it difficult to clean the floors properly. Maintenance had not stripped or re-waxed most of the rooms, despite identifying the issue months prior. Additionally, the facility had a ceiling in disrepair in the Cardinal Hall, with a large dried brown stain, sagging sheetrock, and exposed drywall tape. This damage was attributed to a water leak that occurred months earlier, which had not been repaired. Interviews with residents and staff confirmed the presence of the ceiling damage and expressed concerns about the potential for further deterioration. The Administrator acknowledged the issue but had delayed repairs pending further plumbing work. The facility's failure to address these environmental deficiencies compromised the cleanliness and safety of the living environment. Despite identifying the issues and discussing potential solutions, the necessary maintenance and housekeeping actions were not completed, leading to ongoing concerns about the facility's ability to provide a homelike and sanitary environment for its residents.
Failure to Protect Residents' Personal Possessions During Room Changes
Penalty
Summary
The facility failed to protect the rights of two residents to have and use their personal possessions when they were moved to different rooms. Resident #3 was moved due to water issues in their room, and their belongings, including personal items and furniture, were placed in an unsecured area at the end of the hall. This situation persisted for almost two months, causing frustration and distress to the resident, who repeatedly inquired about returning to their original room. Resident #27 was relocated to allow for air conditioner replacement in their room. Some of their personal items, such as pictures and crafts, were left in the original room, which was subsequently used for storage by maintenance. The resident was not informed about when they could return to their room, and staff did not assist in moving their belongings, leading to the resident feeling upset about the situation. Interviews with staff, including the Certified Medication Tech, Certified Nurse Aide, Social Services Director, and Housekeeping Supervisor, revealed that housekeeping was responsible for moving residents' belongings during room changes. However, in both cases, not all belongings were moved with the residents, and the residents were left uncertain about the status of their original rooms and their personal items.
Failure to Provide Timely Bathing Assistance
Penalty
Summary
The facility failed to provide timely assistance with bathing for two residents, Resident #28 and Resident #14, in a facility with a census of 41. Resident #28, who has multiple diagnoses including multiple sclerosis and end-stage renal disease, required extensive assistance for showers. Despite this, the resident reported not having a shower or bed bath since July 2024, except for one shower on September 23, 2024, after a family member intervened. The Director of Nursing (DON) was unaware of the extent of missed showers and did not receive any complaints from the resident's family. Resident #14, with diagnoses including COPD and Type II diabetes, also experienced infrequent showers. The resident reported feeling dirty and expressed a need for more frequent showers, ideally at least two per week. However, the facility's records showed that the resident received only three showers in August 2024 and two in September 2024. The resident noted that staff often did not have time to assist with showering, leading to infrequent bathing. Interviews with staff revealed systemic issues in the facility's shower scheduling and documentation processes. Certified Nurse Aides (CNAs) were responsible for completing showers, but often could not fulfill this duty due to emergencies or staff shortages. The DON acknowledged that no audits were conducted to ensure showers were completed, and there were issues with the electronic documentation system. The facility lacked a dedicated shower aide every day, and the DON was expected to ensure residents received their scheduled showers.
Failure to Obtain Physician Orders and Timely Urine Sample Collection
Penalty
Summary
The facility failed to adhere to standards of practice by not obtaining a physician's order before administering treatment to a resident with reddened skin. Resident #1, who had a history of diabetes, morbid obesity, and erythema intertrigo, was observed with moist, reddened skin under the abdominal fold. Despite the facility's policy requiring physician orders for treatments, staff applied nystatin to the resident's skin without an order. Interviews with staff revealed a lack of awareness about the need for an order and the presence of redness under the resident's skin fold. Additionally, the facility did not timely obtain a urine sample for a urinalysis ordered for Resident #11, who had diagnoses including diabetes, dementia, and stroke. The resident exhibited symptoms such as increased confusion and vomiting, prompting a physician to order a urinalysis. However, the facility failed to collect the urine sample within the expected timeframe. Interviews indicated a breakdown in communication and procedure, as staff were unsure if the sample had been collected and did not follow up with the physician or other staff members. The deficiencies highlight issues in communication and adherence to protocols within the facility. Staff interviews revealed inconsistencies in following procedures for obtaining physician orders and collecting necessary samples. The Director of Nursing and Administrator acknowledged the lapses, emphasizing the need for staff to follow orders and communicate effectively to ensure timely and appropriate care for residents.
Inadequate Dialysis Care and Communication Deficiency
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident with end-stage renal disease (ESRD), leading to a deficiency in communication and collaboration with the dialysis center. The facility did not consistently monitor the resident's fluid intake as per the care plan, nor did they implement necessary interventions to manage dialysis treatment effectively. The resident's care plan included a renal diet and a 1500 ml fluid restriction, but staff did not consistently document fluid intake during meals, and the resident reported that staff did not monitor their fluid intake, relying instead on the resident to self-monitor. The facility also failed to maintain effective communication with the dialysis center. The communication process between the facility and the dialysis center was inconsistent, with the facility relying on phone calls rather than written communication forms, which had been discontinued. The resident's dialysis book, which was supposed to contain communication forms and laboratory results, was not regularly checked by facility staff, leading to a lack of awareness of the resident's current laboratory results and dialysis-related issues. The resident experienced multiple issues with a clogged shunt, requiring hospital visits and shunt revisions, yet there was no consistent documentation or communication regarding these events. Additionally, the facility did not adequately assess and monitor the resident's dialysis access sites. The resident reported that nurses did not check their ports or shunts for bruits and thrills, and staff interviews confirmed that the assessment of these sites was not consistently performed. The facility's failure to weigh the resident before and after dialysis, as previously done, further contributed to the deficiency in monitoring the resident's condition. The lack of consistent documentation and communication between the facility and the dialysis center, along with inadequate monitoring of the resident's fluid intake and dialysis access sites, led to a deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure that two residents received necessary behavioral health services to maintain their highest practical psychosocial well-being. Resident #24, who had a history of depression, psychosis, and anxiety, expressed a desire to see a psychologist following a recent amputation. Despite this, the facility did not update the resident's care plan to include non-pharmacological interventions or a referral to a psychologist. Observations revealed that the resident remained in a dark room, feeling depressed and expressing a willingness to talk to a psychologist if available. Interviews with staff indicated a lack of awareness and follow-up regarding the resident's psychological needs. Resident #28, diagnosed with multiple sclerosis, diabetes, and depression, also exhibited signs of depression and expressed a desire to speak with a psychologist. The resident's care plan included provisions for psychological services if requested, but no such services were offered. Interviews with staff revealed that the resident's mood had recently worsened, yet there was no follow-up on the resident's request for psychological support. The Social Services Designee (SSD) and other staff members did not routinely ask residents if they wanted to speak with a psychologist, and there was no psychologist visiting the facility. The facility lacked a systematic approach to addressing the behavioral and mental health needs of its residents. Staff interviews highlighted a general unawareness of the procedures for referring residents to psychological services. The Director of Nursing (DON) acknowledged the absence of a visiting psychologist and the challenges in scheduling appointments due to residents' other medical commitments. The facility was in the process of developing a system to address these needs but had not yet implemented it effectively.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a medication pass observation. This deficiency was identified when staff failed to administer ordered medications to two residents. One resident, diagnosed with diabetes mellitus type II, diabetic neuropathy, and chronic pain, did not receive their prescribed pregabalin due to the medication not being available at the facility. The LPN responsible for administering the medication indicated that the pharmacy was awaiting a new physician's prescription before dispensing the medication. Another resident, diagnosed with unspecified osteoarthritis, did not receive their prescribed Tylenol 325 mg tablets. The CMT responsible for administering the medication noted that the facility did not have the medication in stock. Despite searching the medication cart and storage room, the CMT could not locate the Tylenol and documented it as unavailable. The DON later purchased the medication from a store but was unaware that the resident had missed their dose. Interviews with the DON and Administrator revealed that staff were expected to notify the DON if a medication was unavailable, as it might be located elsewhere in the facility. The facility's pharmacy was located out of town, necessitating a backup plan for obtaining medications locally if needed. The failure to administer the ordered medications was considered a medication error, and staff were expected to follow physician orders and notify the pharmacy and physician if medications were unavailable.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, particularly in the administration of insulin and other medications. For one resident with diabetes, the nursing staff did not administer insulin according to the physician's sliding scale orders. The resident often requested partial doses of insulin, which the nurses administered without notifying the physician or documenting the partial doses in the medical records. The resident's care plan lacked specific interventions related to blood glucose and insulin usage, and there were no documented instructions for insulin dosage for certain blood glucose levels. Another resident with end-stage renal disease and dependence on dialysis did not receive multiple doses of medications prescribed to manage chronic kidney disease. The resident frequently missed doses of Veltassa and Auryxia due to being absent from the facility or medication unavailability. The facility's process for ordering and administering these medications was inconsistent, and there was a lack of communication between the staff and the pharmacy regarding medication delivery. The resident's care plan did not accurately reflect the current medications or dietary recommendations necessary for managing elevated phosphorus levels. Interviews with staff revealed a lack of adherence to medication administration protocols and insufficient documentation of medication errors. The facility's Director of Nursing (DON) and other staff members acknowledged the issues with medication administration and documentation but failed to take appropriate actions to rectify the situation. The facility's policies and procedures for medication orders were not effectively implemented, leading to significant medication errors and potential harm to the residents.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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