Country Aire Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewistown, Missouri.
- Location
- 18540 State Highway 16, Lewistown, Missouri 63452
- CMS Provider Number
- 265474
- Inspections on file
- 18
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Country Aire Retirement Center during CMS and state inspections, most recent first.
The facility did not have written policies or procedures for visitation rights, resulting in inconsistent and unclear restrictions on visitors for two residents—one with a guardian and severe cognitive impairment, and another who was cognitively intact. Staff were not consistently informed about visitor limitations, and the reasons for restrictions were not clearly communicated or documented, leading to confusion and distress among residents, staff, and family members.
Staff did not follow professional standards during medication administration, including removing medications from original packaging and placing them in unlabeled cups before the medication pass for multiple residents. Additionally, a CMT failed to administer insulin according to policy by not keeping the insulin pen needle in a resident's skin for the required time, potentially resulting in incomplete dosing.
A resident with severe cognitive impairment was started on Rexulti, an antipsychotic medication, without the facility notifying the responsible party, despite facility policy and care plan requirements for such communication. Family members only learned of the medication after observing changes in the resident's condition and questioning staff.
A certified medication technician crushed and administered extended-release glipizide and metoprolol to a resident with diabetes and hypertension, contrary to physician orders and facility policy, resulting in a significant medication error. The CMT was unaware that these medications should not be crushed, and this was confirmed through observation, record review, and staff interviews.
The facility did not maintain adequate licensed nurse staffing, resulting in an LPN working 36 consecutive hours as the only nurse on duty and being unable to fulfill other assigned roles. Residents and staff reported concerns about exhausted staff, missed care tasks, and unaddressed resident needs, while the facility lacked key nursing positions and was unable to secure additional coverage.
The facility did not provide RN coverage for at least eight consecutive hours daily and failed to have a full-time DON, as required by policy. Staffing schedules and staff interviews confirmed gaps in RN coverage and that the DON role was filled only on paper by a corporate RN who was not present onsite full-time.
Facility administration failed to maintain adequate staffing, leadership, and regulatory systems, resulting in shifts without RN coverage, lack of CPR-certified staff, and absence of a DON, ADON, and Infection Preventionist. Residents and families reported ongoing issues with care, food quality, and supplies, while staff described lack of training, excessive workloads, and no administrative support. The facility also failed to pay vendors for essential supplies and services, leading to disruptions in operations and storage of sensitive records inappropriately.
The facility did not respond to repeated Resident Council concerns about care and quality of life, including issues with food temperature, loud televisions, lack of proper incontinence supplies, and missing water for oxygen concentrators. Staff confirmed that concerns were forwarded to administration and department heads, but no actions were taken or documented, and a resident reported ongoing unresolved issues with care and equipment.
Staff did not implement physician-ordered droplet precautions for several residents with respiratory symptoms, and failed to administer medications as ordered for other residents. Despite clear orders and facility policy, precautions were not followed and residents reported missed or incorrect medications, with no documentation of refusals or corrective action taken.
The facility did not ensure that a CPR-certified staff member was scheduled on every shift, leaving multiple night shifts without certified personnel despite having residents with full code status. There was no policy in place for CPR certification requirements, and documentation of staff certifications was incomplete or outdated. Leadership and scheduling staff were aware of the need for CPR-certified coverage but did not maintain compliance.
The facility did not have a functioning antibiotic stewardship program or a designated Infection Preventionist (IP), as required by its own policies. The only full-time RN, who previously served as IP, was unable to continue due to workload, and there was no tracking of infections or antibiotic use. Interviews with corporate and administrative staff confirmed the lack of oversight and documentation for infection control and antibiotic monitoring.
A resident with multiple Stage IV pressure ulcers did not receive consistent weekly wound measurements or skin assessments as required by facility policy. Staff performed wound care but failed to document or measure wounds regularly, and there was no communication of wound status to the physician. The lack of a designated wound nurse and insufficient monitoring by nursing leadership contributed to the deficiency.
The facility failed to maintain RN coverage for at least eight hours a day, seven days a week, and did not have a full-time DON. Staffing schedules showed multiple days without RN presence, with only a corporate RN available by phone. The DON resigned, leaving the facility with one full-time RN and two as-needed RNs, despite efforts to recruit more staff. This compromised the facility's ability to meet resident care needs.
A facility failed to protect two residents from the misappropriation of their narcotic medications by an RN who signed for receiving the medications but did not document their administration or destruction. The medications were not found in the facility, and the RN re-ordered them multiple times without justification. The residents did not report receiving or requesting the medications, and the RN was the only staff member with access during the shifts in question.
The facility was found deficient in maintaining kitchen cleanliness and proper food handling practices. Observations showed a buildup of grease on the range hood, debris on the air conditioner and microwave, and improper food storage. The Dietary Manager was unaware of cleaning responsibilities, and food handling practices were inadequate, with staff not washing hands between tasks and improper use of hair restraints. Additionally, the ice machine lacked an air gap, and a light fixture cover was damaged.
The facility failed to maintain the dignity of three residents by not covering their urinary catheter bags, as required by policy. Observations showed that the catheter bags of a cognitively impaired resident, a cognitively intact resident, and another resident requiring substantial assistance were left uncovered in public areas. Staff interviews confirmed the expectation for dignity covers, but the facility lacked sufficient covers for all residents with catheters.
The facility failed to properly manage the resident trust fund account by not maintaining accurate monthly reconciliations. The Business Office Manager only reconciled petty cash, while corporate staff handled bank accounts. Monthly transfers of $1,500 were made to prevent negative balances, but these were not accounted for in reconciliations. The Administrator expected correct reconciliation, but it was not achieved.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their medical conditions and treatments. A resident's dialysis treatment was omitted, another's intellectual disability was not recorded, and pressure ulcers were inaccurately staged. The MDS coordinator acknowledged these oversights, and the DON expected accurate assessments reflecting current conditions.
The facility exhibited significant deficiencies in infection control practices, including inadequate hand hygiene, improper use of PPE, and poor urinary catheter care. Staff failed to consistently wash hands and use gowns during high-contact activities, and catheter bags were often found touching the floor. Additionally, soiled materials were not handled in a sanitary manner, contributing to the risk of infection.
The facility failed to maintain the three-compartment sink in the kitchen, which had been leaking and lacked hot water for approximately one year. Despite awareness from the maintenance team and the Administrator, the issue remained unresolved, affecting kitchen operations.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for three residents. Despite the facility's policy requiring regular safety checks, there was no documentation of entrapment zone measurements for these residents, who used bed rails or assist bars. Observations confirmed the presence of raised assist bars or bed rails, but necessary safety checks were not documented. Interviews revealed that maintenance staff did not complete or track required measurements, and compatibility with specialty mattresses was not checked.
The facility did not post the required contact information for the state survey agency and elder abuse hotline. Observations showed the information was not visible, and interviews with residents and staff confirmed they were unaware of its location. The Administrator was unaware of the oversight.
The facility failed to provide timely NOMNCs to three residents, not adhering to the required two-day notice period before Medicare coverage ended. Staff interviews revealed a lack of awareness and training on issuing these notices, and the facility could not provide a policy on the matter.
The facility failed to post required nurse staffing information, including licensed and unlicensed staff hours, as mandated by policy. Observations showed missing or incomplete postings, and interviews confirmed the deficiency. Approximately one-third of the staffing sheets over 18 months were blank, lacking necessary details.
Failure to Establish and Communicate Visitation Rights Policy
Penalty
Summary
The facility failed to have written policies and procedures regarding visitation rights, including the management of restrictions placed on two residents' visitors. The Administrator confirmed that there was no policy in place addressing visitation rights, and staff were not provided with clear guidance or communication about the reasons for visitor limitations. The facility's existing Resident Rights policy required informing residents and their representatives of their rights and responsibilities, but did not address the process for restricting visitors or communicating such restrictions to staff. For one resident with severe cognitive impairment and a legal guardian, the guardian provided a list of individuals who were not allowed to visit. This list was included in the resident's care plan and posted at the nurse's station, instructing staff to deny access to those individuals and contact authorities if necessary. However, staff interviews revealed confusion and lack of awareness about the restrictions, with some staff only discovering the list after incidents occurred. The rationale for the restrictions was not discussed with the guardian, and there was no documentation of official reasons or supporting court documents for the exclusions, despite allegations of past financial exploitation and family discord. Another resident, who was cognitively intact and had no guardian, was also affected when a family member was barred from visiting after an incident involving another resident. The family member was told by law enforcement not to return to the facility, which caused distress for the resident who had previously received frequent visits. Staff interviews indicated uncertainty about the authority and process for restricting visitors, and the chain of command was not consistently followed. The lack of a formal policy and clear communication led to inconsistent application of visitor restrictions and confusion among staff and visitors.
Failure to Follow Professional Standards in Medication and Insulin Administration
Penalty
Summary
Staff at the facility failed to adhere to professional standards of practice during medication administration for multiple residents. Certified Medication Technicians (CMTs) were observed removing medications from their original packaging and placing them into unlabeled medication cups with only the resident's first name written on the side, prior to the scheduled medication pass. This practice was observed for 13 residents, and the cups were stored in the medication cart drawers until administration. The medications in the cups were not labeled to indicate their contents, and the CMT acknowledged that this was done to expedite the medication pass, despite knowing that medications should not be removed from packaging until the time of administration. The Director of Nursing confirmed that this practice was not in accordance with facility policy and could lead to medication errors. Additionally, staff failed to follow the facility's policy and manufacturer instructions for insulin administration for a resident with diabetes. The CMT administering insulin did not keep the insulin pen needle in the resident's skin for the required 6-10 seconds after pressing the plunger, as specified in both the facility's policy and the medication instructions. Instead, the needle was removed immediately after the dose counter reached zero, potentially resulting in incomplete administration of the prescribed insulin dose. The CMT stated they were unaware of the need to keep the needle in place for the specified duration.
Failure to Notify Representative of New Antipsychotic Medication
Penalty
Summary
The facility failed to notify a resident's representative when a new antipsychotic medication, Rexulti, was initiated. The resident, who had severe cognitive impairment, disorganized thinking, and inattention, was started on Rexulti for anxiety as documented in the physician's orders. Despite the resident's significant cognitive deficits and the presence of a responsible party who had signed the consent to treat form, there was no evidence in the progress notes that the responsible party was informed of the new medication. The facility's own Resident Rights form and care plan required notification and education of the resident or family regarding changes in care and treatment, including new medications. Interviews with family members revealed that they were not notified about the initiation of Rexulti and only became aware of the medication after noticing changes in the resident's behavior, such as increased grogginess and difficulty with speech. The DON stated an expectation that responsible parties should be notified of new medications, while the Administrator expressed uncertainty about the requirement to notify family members in the absence of a legal POA. The facility's failure to notify the resident's representative of the new medication constituted a deficiency in communication and adherence to resident rights.
Crushing and Administering Extended-Release Medications
Penalty
Summary
A certified medication technician (CMT) crushed and administered two extended-release medications, glipizide ER and metoprolol ER, to a resident diagnosed with diabetes and hypertension. The medications were intended to be taken whole, as per physician orders and manufacturer instructions, to ensure gradual release over 24 hours. The CMT was observed removing the tablets from the medication cart, crushing them, mixing them with yogurt, and administering them to the resident. Documentation in the Medication Administration Record confirmed that both medications were given in the morning as prescribed, but in crushed form. During interviews, the CMT stated they were unaware that the medications were extended-release and should not be crushed, acknowledging that crushing such medications would result in the entire dose being absorbed at once rather than over 24 hours. The Director of Nursing and the Administrator both confirmed that extended-release medications should not be crushed, as this practice is inconsistent with facility policy and standard medication administration protocols. The facility's policy and drug information resources also specify that extended-release medications must be swallowed whole and not crushed.
Failure to Maintain Adequate Licensed Nurse Staffing
Penalty
Summary
The facility failed to provide an adequate number of licensed nurses on duty to meet the needs of all residents, as required by policy. The Social Service Director, who was also a Licensed Practical Nurse (LPN), was repeatedly pulled from their primary duties to serve as the only charge nurse on multiple occasions, including working 36 consecutive hours without relief. During this extended shift, the LPN was observed sleeping in a recliner at the nurse's station due to exhaustion. The facility's staffing records confirmed that this LPN was the sole licensed nurse in the building for three consecutive 12-hour shifts. Additionally, the facility lacked an Infection Preventionist, a designated wound nurse, and an Assistant Director of Nursing due to ongoing staffing shortages. Interviews with residents and staff revealed significant concerns about the lack of nursing staff. Multiple residents expressed worry about the safety and adequacy of care, noting that the LPN was visibly exhausted and that other staff, such as a Certified Medication Technician, also worked extended hours to support the LPN. Residents reported issues such as infrequent showers, unchanged bed linens, and improper maintenance of medical equipment like oxygen concentrators. Staff interviews confirmed that the LPN was unable to fulfill their social service duties or follow up on resident concerns due to being consistently assigned to nursing shifts. The only full-time RN was leaving employment, and the facility had been unable to secure additional licensed nurse coverage through staffing agencies. The facility's own assessment indicated a need for more RNs and LPNs than were currently employed, and the census included residents with complex care needs, such as those with contractures, psychiatric diagnoses, pressure ulcers, and specialized treatments. The lack of adequate licensed nursing staff resulted in incomplete wound assessments, missed routine skin checks, and insufficient documentation. Corporate and administrative staff acknowledged the staffing shortages and the inability to cover necessary shifts, confirming that essential care tasks were not being completed as required.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not ensure a full-time RN was designated as the Director of Nursing (DON). Review of staffing schedules showed that there was no RN coverage on two specific days, and interviews with staff confirmed that the facility only had one full-time RN, whose last day was shortly after the deficiency was identified. After this RN's departure, only one as-needed (PRN) RN remained, and attempts to secure routine RN coverage through a staffing agency were unsuccessful. Interviews with various staff and corporate personnel revealed that the facility had been listing a corporate RN as the DON on paper, but this individual was rarely present onsite and was not available on a full-time basis. The facility's own policies required a full-time DON and RN coverage for eight hours daily, but these requirements were not met. The administrator and other staff acknowledged the lack of consistent RN presence and the absence of a full-time DON in the building.
Failure to Maintain Adequate Staffing, Leadership, and Regulatory Systems
Penalty
Summary
Facility administration failed to ensure effective and efficient operations, resulting in multiple regulatory deficiencies. The facility did not have a full-time Director of Nursing (DON), Assistant Director of Nursing (ADON), or an adequate number of licensed nurses to meet resident needs. There was also no Infection Preventionist (IP) or antibiotic stewardship program in place, and the facility was not tracking antibiotic use or infections. Staffing schedules revealed shifts without Registered Nurse (RN) coverage, and several shifts lacked staff with current CPR certification. New nurse assistants reported receiving only onboarding videos with no further training or education, and there was no designated person for staff to approach with questions or concerns. The administrator was seldom present, and staff, including the HR Director and Social Service Director, confirmed ongoing issues with expired or missing CPR certifications and lack of leadership presence. Residents and their families reported ongoing concerns, including insufficient nurse staffing, lack of response to grievances, and persistent issues with food quality, incontinence supplies, and basic care such as showering and linen changes. Resident Council minutes documented repeated complaints about cold food, loud televisions, and inadequate snacks, with no documented staff response. One resident stated that their oxygen concentrator was not properly maintained, and another family member had to purchase incontinence briefs due to facility shortages. Staff interviews corroborated these issues, with reports of exhaustion from working excessive hours due to lack of licensed nurse coverage and no administrative follow-up on resident concerns. The facility also failed to pay vendors for essential supplies and services in a timely manner, resulting in credit holds and inability to reorder necessary items. The maintenance supervisor reported that document shredding services were suspended due to unpaid bills, leading to storage of sensitive records in a shed. The business office manager and corporate staff were unaware of outstanding bills, and the administrator was not informed of these financial issues. The medical director expressed concern about the lack of leadership, absence of required administrative roles, and the facility's inability to meet residents' needs. There was no evidence of infection control tracking or an antibiotic stewardship program, and the facility did not have a designated wound nurse.
Failure to Address Resident Council Grievances and Provide Responses
Penalty
Summary
The facility failed to act promptly on grievances and recommendations made by the Resident Council regarding resident care and quality of life issues. Despite holding monthly Resident Council meetings where residents raised concerns such as loud televisions, inappropriate food options, lack of proper incontinence supplies, absence of water for oxygen concentrators, and dissatisfaction with snacks and meal temperatures, there was no documented response from staff or administration to address these issues. Review of the Administrator's job description indicated a responsibility to review complaints and make written reports of actions taken, but the Administrator was unsure if a written policy on council meetings existed and confirmed only that meetings were held monthly. Interviews with staff and residents revealed ongoing dissatisfaction and a lack of resolution to repeated concerns. A resident reported not having anyone to address their issues, including infrequent showers, unchanged sheets, and an oxygen concentrator without water for humidification, which was confirmed by observation. The Social Service Director/LPN stated that concerns from Resident Council meetings were passed to the previous Administrator and department heads, but no actions were taken. The new Administrator, who had just started, expected policies and regulations to be followed but acknowledged the lack of documented responses to resident concerns.
Failure to Follow Physician Orders for Droplet Precautions and Medication Administration
Penalty
Summary
The facility failed to follow professional standards of practice by not implementing physician-ordered droplet precautions for four residents who exhibited respiratory symptoms such as cough, congestion, and fever. Despite clear orders from the Medical Director to place symptomatic residents on droplet precautions to prevent the spread of infection, staff did not follow these orders. Observations confirmed the absence of required signage and precautions, and interviews with staff revealed that the previous administrator instructed staff to disregard the droplet precaution orders due to the lack of a definitive diagnosis, even though the orders remained in the residents' charts. Additionally, the facility did not ensure that physician orders for medications were followed for three residents. In several instances, an agency RN was documented as having administered medications, including insulin and other routine morning medications, but residents reported that they either did not receive their medications or were given incorrect medications. These residents, who were cognitively intact and familiar with their medication regimens, reported the discrepancies to facility leadership. There was no documentation of medication refusals, and the agency RN did not provide the correct medications as ordered. Multiple staff interviews corroborated that there were widespread complaints from residents about missed or incorrect medication administration by the agency RN. The facility's own policies required prompt and accurate implementation of physician orders, regular audits, and corrective actions for discrepancies, but these were not followed. The administrator was unable to provide evidence of any education or corrective action taken with the agency RN after the incidents were reported.
Failure to Ensure CPR-Certified Staff Coverage and Maintain Certification Records
Penalty
Summary
The facility failed to ensure that CPR-certified staff were scheduled on all shifts, as required for residents with full code status. A review of staffing records and CPR certification documentation revealed that on multiple night shifts, there was no staff member present with a valid CPR certification. The facility had 13 residents designated as full code, meaning they required full resuscitation efforts in the event of cardiac arrest. Additionally, the facility did not have a policy addressing CPR requirements for staff, nor did it maintain up-to-date documentation of staff CPR certifications. Interviews with facility staff indicated a lack of clarity and oversight regarding CPR certification status. The HR Director reported that many staff had expired certifications or lacked documentation, and that the responsibility for arranging CPR classes had not been fulfilled. The staff member responsible for scheduling was unaware of which employees held current certifications, and both the Administrator and other leadership acknowledged that a CPR-certified staff member should be present on each shift. Despite this, the facility did not ensure compliance, resulting in shifts without appropriately certified personnel.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program (IPCP) that included an antibiotic stewardship program and a system to monitor antibiotic use. Review of the facility's Infection Control Policy and Procedure indicated requirements for evidence-based infection prevention practices, oversight by a designated Infection Preventionist (IP), surveillance of infections, prevention strategies, education, and regular review of antibiotic use. However, interviews and record reviews revealed that the facility did not have a functioning antibiotic stewardship program or a designated IP. The only full-time day shift RN, who previously served as the IP, reported being unable to fulfill IP duties due to workload and overtime, and confirmed that the facility was not tracking infections or antibiotic use. Further interviews with a corporate RN and the facility administrator confirmed the absence of an IP and lack of documentation regarding infection or antibiotic use tracking. The administrator, who had recently started, acknowledged the expectation for a designated IP or for the DON to fulfill that role, and that the facility should follow its infection control policies and CDC guidelines. The facility census at the time was 37, and there was no evidence of an active system to monitor or review antibiotic use as required by policy.
Failure to Provide Consistent Pressure Ulcer Assessment and Documentation
Penalty
Summary
Facility staff failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers and prevent new ulcers from developing for a resident with multiple Stage IV pressure ulcers. The resident was identified as at risk for pressure ulcers, with a Braden Scale score indicating risk, and had a history of multiple pressure ulcers present upon admission, including Stage III, Stage IV, and unstageable ulcers. The care plan included interventions such as frequent repositioning, use of pressure-reducing devices, dietary consults, and wound care treatments, as well as regular wound assessments and documentation. Despite these interventions being outlined in the care plan and facility policy, staff did not consistently perform or document weekly wound measurements or skin assessments as required. Nursing notes and skin assessments over several months showed no evidence of weekly wound measurements or completed skin assessments. During observation, a registered nurse performed wound care but did not measure the wounds, and staff interviews confirmed that wound measurements and assessments were not being completed as per policy. Staff cited short staffing and workload as reasons for not completing required documentation and assessments. Additionally, there was a lack of communication with the physician regarding the status of the wounds, as the physician reported not receiving any wound documentation or weekly reports. The facility did not have a designated wound nurse, and the Director of Nursing or designee was not monitoring wounds as required. The failure to follow facility policy and standard wound care practices resulted in inadequate monitoring and documentation of the resident's pressure ulcers.
Failure to Maintain RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not ensure a full-time Director of Nursing (DON) was designated. The facility's assessment indicated the need for a DON and two full-time RNs, but staffing schedules revealed significant gaps in RN coverage. On multiple occasions in December 2024 and January 2025, there was no RN coverage in the facility, with a corporate RN only available by phone. The facility's policies required adequate staffing to meet resident needs, but these were not adhered to, resulting in insufficient RN presence. Interviews with the Administrator in Training (AIT) and the Administrator highlighted the challenges faced by the facility in maintaining adequate RN staffing. The DON had resigned on December 29, 2024, leaving the facility with only one full-time RN and two RNs working as needed. Despite efforts to recruit through staffing agencies and corporate support, the facility struggled to fill the RN and DON positions. The lack of a full-time DON and consistent RN coverage compromised the facility's ability to meet the nursing care needs of its residents, as outlined in their policies and the Centers for Medicare and Medicaid Services guidelines.
Misappropriation of Narcotic Medications by RN
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their narcotic medications by a Registered Nurse (RN) who was also the Former Assistant Director of Nursing (ADON). The RN signed for receiving narcotic medications from the pharmacy for two residents but did not document their administration or destruction. The medications were not found in the facility after being received by the RN, indicating a misappropriation of property. Resident #1, who had a diagnosis of complete traumatic amputation at the level between the knee and ankle, was prescribed oxycodone-acetaminophen for pain management. Despite receiving multiple deliveries of this medication, there was no documentation of its administration, and the resident reported not requesting or receiving pain medication. The RN re-ordered the medication multiple times without justification, and the medication was not logged into the narcotic count/lock box. Resident #2 had an order for hydrocodone-acetaminophen for hand pain but similarly showed no documentation of administration. The RN discontinued the order in the computer system and signed for a delivery of the medication, which was not logged into the narcotic count/lock box. The facility's investigation revealed that the RN was the only staff member with access to the medications during the shifts in question, and the narcotics were ordered and received by the RN without being accounted for in the facility.
Deficiencies in Kitchen Cleanliness and Food Handling Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper food handling practices in the kitchen, leading to multiple deficiencies. Observations revealed a significant buildup of grease and debris on the range hood and filters, which had not been cleaned as per the facility's policy. The Dietary Manager was unaware that the responsibility for cleaning the hood filters fell on the dietary staff, and the Maintenance Supervisor was unsure of the last cleaning date. Additionally, the air conditioner and microwave in the kitchen were found with a heavy buildup of debris, and the microwave showed signs of rust and damage. Food storage practices were also found to be inadequate. Several food items in the refrigerator and freezer were uncovered, unlabeled, or not dated, contrary to the facility's policy. This included ice cream, burritos, hamburger patties, and various other food items. The Dietary Manager reheated and served chicken noodle soup that was improperly dated, and several spice containers were left open and unsealed. The water dispenser and its filter were not maintained properly, with a buildup of debris observed on the dispensing spout. The facility also failed to ensure safe food handling practices. The Dietary Manager was observed handling food with gloves without washing hands between tasks, and staff did not wear hair restraints properly, leaving hair exposed while handling food. Furthermore, the ice machine lacked an appropriate air gap to prevent back siphonage, and a light fixture cover in the kitchen was damaged, posing potential contamination risks. Interviews with the Dietary Manager and Maintenance Supervisor revealed a lack of awareness and adherence to the facility's policies regarding these issues.
Failure to Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure the dignity and respect of three residents by not covering their urinary catheter bags, as required by the facility's policy. The policy, dated August 2009, mandates that each resident should be cared for in a manner that promotes dignity and prohibits demeaning practices. Specifically, the policy requires staff to assist residents in keeping urinary catheter bags covered. However, observations revealed that the urinary catheter bags of Residents #40, #293, and #35 were consistently left uncovered in public areas, compromising their dignity. Resident #40, who was cognitively impaired and dependent on assistance for toileting, was observed multiple times in the common area and dining room with an uncovered urinary catheter bag. Despite the care plan indicating the need for a dignity cover, the bag remained exposed on several occasions, including during meals and in the presence of other residents. Similarly, Resident #293, who was cognitively intact and independent for toileting, was observed with an uncovered catheter bag while dining and moving around the facility. The lack of a dignity cover was noted during interactions with staff and other residents. Resident #35, who was cognitively impaired and required substantial assistance for toileting, also had an uncovered urinary catheter bag during meals and while being transferred by staff. Interviews with facility staff, including CNAs and the Infection Preventionist/RN, confirmed that catheter bags should always have dignity covers. The Director of Nursing acknowledged the issue and admitted that the facility did not have enough dignity covers for all residents with urinary catheters.
Deficiency in Resident Trust Fund Account Management
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. The facility managed funds for 25 residents, and the census was 43. A request for a facility policy regarding the reconciliation of the resident funds account was made, but none was provided. Record reviews showed no reconciliation for the full resident trust account, and the Corporate Accountant's attempted reconciliation for specific accounts showed no reconciliations for the period from June 2023 through June 2024. Interviews revealed that the Business Office Manager (BOM) only reconciled the petty cash accounts, while corporate staff reconciled the bank accounts. The BOM and Corporate Accountant confirmed that only petty cash was reconciled, and the facility management company staff indicated that $1,500 was transferred monthly to the resident trust account to prevent negative balances. However, the reconciliation did not account for these transfers, and there was no documentation to verify the source of the petty cash funds. The Administrator expected the resident funds account to be reconciled correctly, but this was not the case.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete comprehensive assessments for three residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #25's quarterly Minimum Data Set (MDS) did not document the resident's ongoing dialysis treatment, despite the resident's care plan and physician orders indicating regular dialysis sessions. The MDS coordinator admitted to an oversight in failing to include this critical information. Similarly, Resident #2's MDS lacked documentation of a severe intellectual disability, a condition confirmed in the resident's physician progress notes. The MDS coordinator was unaware of this diagnosis, resulting in an inaccurate assessment. Resident #18's MDS inaccurately documented the presence of three stage III pressure ulcers upon readmission, while the nursing admission screening indicated the presence of stage II pressure ulcers. The MDS coordinator acknowledged the error after reviewing the resident's medical records, which showed no evidence of the ulcers worsening. The Director of Nursing (DON) expected the MDS to be accurate and reflective of current resident conditions, but the inaccuracies in these assessments indicate a failure to meet these expectations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control procedures, particularly in hand hygiene and the use of personal protective equipment (PPE). Observations revealed that staff did not consistently wash their hands before and after resident contact, nor did they use gowns when required for Enhanced Barrier Precautions (EBP). For instance, the Assistant Director of Nursing (ADON) and other staff members were observed performing wound care and other high-contact activities without wearing gowns, despite the presence of wounds and indwelling medical devices that necessitated such precautions. Additionally, signage indicating EBP was often missing from resident rooms, and PPE was not readily available, further contributing to the lapses in infection control. The facility also failed to maintain proper urinary catheter care, as drainage bags were frequently observed touching the floor, which poses a risk for contamination and infection. This was noted for several residents, including those with urinary catheters for retention or other medical conditions. Despite facility policies requiring that catheter bags be kept off the floor, observations showed that bags were often found dragging on the ground or resting directly on the floor, both in resident rooms and common areas. Furthermore, the handling of soiled materials and the execution of perineal care were not conducted in a sanitary manner. Staff were seen placing soiled washcloths on surfaces without barriers and failing to perform hand hygiene after removing gloves or handling contaminated items. These actions were contrary to the facility's policies and expectations for infection prevention, as stated by the Director of Nursing and the Infection Preventionist. The lack of adherence to these protocols highlights significant deficiencies in the facility's infection control practices.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good working order, specifically the three-compartment sink used for sanitizer solution. Observations revealed that the drain pipe for the third sink well was leaking, causing water to overflow from a plastic tub onto the floor. The Dietary Manager confirmed that the pipes under the sink leaked due to broken seals and that the sink lacked hot water. Despite being aware of these issues, the maintenance team and the Administrator had not resolved the problem, which had persisted for approximately one year. Interviews with the Maintenance Supervisor and the Administrator indicated that the sink had not functioned properly for at least six months, and previous repair attempts were unsuccessful. The facility was in the process of finding a custom-built replacement due to size constraints in the kitchen. The kitchen staff had stopped using the sink for washing large items or dishware when the dish machine was broken, highlighting the ongoing impact of the deficiency on kitchen operations.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for three residents. The facility's policy, dated December 2007, required maintenance staff to inspect all beds and related equipment as part of a regular bed safety program. However, there was no documentation of entrapment zone measurements for Residents #24, #25, and #40, despite their use of bed rails or assist bars. Observations confirmed that these residents had assist bars or bed rails in the raised position, but the necessary safety checks were not documented. Resident #40, who was cognitively intact but had upper and lower extremity impairments, was observed with assist bars on both sides of the bed. The resident's Bed Rail Assessment indicated a need for these bars to promote independence, yet there was no documentation of entrapment zone measurements. Similarly, Resident #24, who required substantial assistance with bed mobility, had mobility bars as per physician orders, but again, no entrapment zone measurements were documented. Resident #25, also non-ambulatory and requiring assistance, had quarter bed rails, but the necessary safety checks were not recorded. Interviews with facility staff revealed gaps in the implementation of the bed safety policy. The Maintenance Supervisor admitted to installing bed rails without completing or tracking the required measurements and did not check compatibility with specialty mattresses. The DON stated that maintenance staff were responsible for measuring entrapment zones and ensuring compatibility, but these tasks were not completed as expected. The Administrator acknowledged that maintenance and nursing staff should collaborate to ensure these measurements are completed and tracked, as per facility policy.
Failure to Post State Agency and Elder Abuse Hotline Information
Penalty
Summary
The facility failed to ensure that the telephone number and contact information for the state survey agency and the elder abuse hotline were posted in the facility, as required by federal and state laws. Observations conducted over several days revealed that there was no visible posting of this information throughout the facility. Although the elder abuse hotline number was found in the front foyer area, it was not readily visible to those entering the facility, and the state survey agency contact information was not posted at all. Interviews with residents and staff further confirmed the deficiency. During a group resident council interview, residents expressed that they were unaware of where the contact information for the state survey agency or elder abuse hotline was posted. A resident also stated that they had not seen the numbers posted anywhere in the facility, only the Resident's Rights posters in the hallways. The Human Resources staff member corroborated this by stating that she could not find the contact information posted anywhere in the facility. The Administrator acknowledged that social services were responsible for posting the information and admitted that he was unaware it was not posted throughout the facility.
Failure to Timely Issue NOMNCs
Penalty
Summary
The facility failed to provide timely Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) to three residents, as required by regulations. The NOMNC should be delivered at least two calendar days before Medicare coverage services end. However, the facility did not meet this requirement for three residents. Resident #343 received the NOMNC one day before the last skilled day, Resident #34's representative received it on the same day as the last skilled day, and Resident #344's representative received it one day before the last skilled day. This indicates a failure to comply with the required notice period. Interviews with facility staff revealed a lack of awareness and training regarding the issuance of NOMNCs. The Social Services Director (SSD) admitted to being unaware of the two-day notice requirement and stated that they had never been trained in issuing Advance Beneficiary Notices (ABNs) or NOMNCs. The Administrator expected the Business Office Manager or SSD, in collaboration with Therapy, to issue the notices according to regulations, but this expectation was not met. The facility also failed to provide a policy regarding the issuing of NOMNCs when requested.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the facility name, resident census, and total actual hours worked by both licensed and unlicensed nursing staff per shift. Observations on multiple occasions revealed that the required staffing information was not posted in a prominent location as mandated by the facility's policy. On one occasion, the Administrator in Training admitted to removing the postings because a resident was tearing them off the bulletin board. Further observations showed that the posted nurse staffing sheet only contained census information without the necessary details of licensed or unlicensed staffing numbers or hours for each shift. A review of the facility's records over an 18-month period revealed that approximately one-third of the nurse staffing sheets were blank and lacked the required information. Interviews with the Director of Nursing and the Administrator confirmed the deficiency, with both expressing expectations that the staffing sheets should be completed accurately and posted conspicuously as per regulations. The failure to maintain and display accurate staffing information as required by policy and regulations was evident, leading to the deficiency noted in the report.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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