Eldon Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Eldon, Missouri.
- Location
- 1001 East North Street, Eldon, Missouri 65026
- CMS Provider Number
- 265555
- Inspections on file
- 19
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Eldon Nursing & Rehab during CMS and state inspections, most recent first.
Infection control failures were observed during perineal care and wound care when staff did not change gloves between dirty and clean tasks, did not perform hand hygiene at required points, and handled wound supplies and resident items without maintaining sanitary technique. Multiple residents with wounds or indwelling catheters also had no EBP signage posted, and catheter tubing was observed dragging on the floor or a catheter bag was placed above the bladder, allowing urine backflow. Staff interviews showed awareness of some infection control expectations, but EBP signage use was not understood by all staff.
Failure to implement an ASP and monitor antibiotic use: the facility did not maintain a complete infection/antibiotic control log for several months, and the logs that were reviewed showed repeated missing documentation for signs and symptoms, site of infection, onset of symptoms, culture status, pathogen identification, and whether the infection resolved. The IP said he/she gathered antibiotic-use information but did not know what information was required, while the DON, ADON, and administrator identified the IP as responsible for tracking and trending antibiotic use and infections.
Failure to Provide Timely Incontinent and Hygiene Care: Staff did not consistently provide toileting, peri-care, or clothing changes for three dependent residents with urinary incontinence and significant ADL needs. Observations showed residents sitting in wet clothing with strong urine odor and urine puddles under wheelchairs in common areas and the dining room, while interviews showed residents were left wet for long periods and staff were inconsistent about checking, changing, and documenting care. Care plans lacked or did not consistently reflect needed interventions for frequent checks and behavior-related refusals, and staff reported inconsistent follow-through with incontinent care.
Failure to Complete AMA Documentation: Staff did not complete the required AMA release documentation when a cognitively intact resident became upset about being at the facility, packed clothes, and left with a family member against medical advice. The chart showed the physician and DON were notified, but the EMR contained no AMA form, and interviews confirmed staff expected the form to be completed and documented if the resident refused to sign.
Medication error rates exceeded the allowed threshold, with 3 errors in 34 observed opportunities for a 9.68% error rate. A CMT crushed part of a resident’s medication dose without a physician order after giving part of the dose, and both the DON and administrator stated staff are expected to follow physician orders and not crush medications without an order.
Care plans were not updated to reflect current needs for three residents. One resident with paraplegia and a right-hand contracture had no contracture interventions on the care plan, even though staff observed the contracted hand and an LPN and the DON expected it to be addressed. A second resident with multiple wounds had no wound or prevention interventions on the care plan, and a third resident with PVD/CVI and bilateral leg edema had no edema interventions despite wound orders, repeated observations of swollen red legs, and staff stating edema should have been included.
Facility staff failed to update the Facility Assessment at least annually. Review of the assessment showed no documentation that it was reviewed for the current year, and the administrator stated she did not know why it had not been reviewed or updated since the prior year. The DON was not aware the assessment had not been updated and said the administrator would be responsible for the process.
Multiple residents who required assistance with showers did not consistently receive this care, as evidenced by missing documentation, resident interviews, and observations of poor hygiene. Staff cited time constraints and lack of available personnel for two-person assists as reasons for incomplete care, and leadership had not recently reviewed shower records, resulting in unmet hygiene needs.
Staff failed to document assessments and obtain physician orders for new wounds in a resident with multiple pre-existing wounds and severe cognitive impairment. Despite facility policy requiring specific orders and documentation, new wounds were identified but not properly assessed or treated according to protocol, and records lacked evidence of timely interventions.
A resident with moderate cognitive impairment and ongoing tooth pain, including broken teeth and facial swelling, did not receive timely assistance from staff to schedule a dental appointment despite repeated complaints and requests for pain relief. The social worker, responsible for arranging dental care, was aware of the issue but did not act, and facility records showed no attempts to secure dental services for the resident.
The facility did not ensure that residents were protected from all forms of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report does not provide additional details about the specific events or individuals involved.
Staff did not report an allegation of abuse involving a cognitively impaired resident with visible injuries to the state agency within the required two-hour timeframe. An LPN notified the DON about the injuries and the resident's statement, but the DON determined it was not reportable, and the incident was not escalated to the administrator or reported to authorities as required by policy.
Staff did not initiate or complete an investigation after a resident with severe cognitive impairment was found with a black eye and bruising and stated someone hit them. Although the LPN reported the incident to the DON, no formal investigation was conducted, and the incident was not reported to the state, contrary to facility policy.
A resident with moderate cognitive impairment exhibited repeated physical and verbal aggression toward others, as documented in nurse's notes, but staff failed to update the care plan to reflect these behaviors or include interventions. Interviews with CNA, RN, MDS Coordinator, DON, and the administrator confirmed that such behaviors should be care planned, but the omission was attributed to a lack of reporting or communication.
A cognitively impaired resident with a history of wandering and exit-seeking was able to leave the facility undetected, access a transport van with keys left inside, and drive several miles away. Staff had not updated the care plan or completed required elopement assessments after previous incidents, and the facility's elopement policy was not followed, resulting in the resident's absence only being discovered after notification by law enforcement.
A resident with cognitive impairment, delirium, and daily wandering behaviors was not properly assessed for elopement risk. The initial assessment inaccurately identified the resident as low risk, and subsequent assessments were left incomplete. Staff interviews revealed confusion over assessment responsibilities, and the facility's policy lacked clear instructions for completing elopement assessments.
Facility staff failed to properly store and label medications, with expired items and loose tablets found in storage areas. Staff interviews revealed inconsistent monitoring and accountability, with a CMT not checking carts due to vacation and the DON and administrator acknowledging the need for regular checks. This indicates a breakdown in medication management processes.
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which required signage and PPE for residents with wounds or indwelling devices. Observations showed that staff did not post EBP signage or provide PPE outside the rooms of affected residents, and staff did not wear gowns during care. Interviews revealed a lack of awareness and understanding of the EBP policy among staff, with concerns about resident dignity and unclear responsibility for oversight.
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in providing adequate nutrition. Despite RD recommendations for supplements and weight monitoring, these were not communicated to the physician or implemented. Staff interviews revealed a lack of awareness regarding the need for supplements and meal intake monitoring, and systemic issues in policy and communication contributed to the deficiency.
The facility failed to establish an agreement and maintain communication with a dialysis facility for a resident with ESRD. Despite having a policy requiring communication records, no agreement was in place, and no paperwork was sent with the resident on dialysis days. The resident's care plan lacked guidance on communication, and staff were not trained on dialysis or renal disease. Interviews revealed a lack of awareness and responsibility among staff regarding these requirements.
A resident with a history of cognitive changes and behavioral episodes was observed by a family member with their hand down another resident's pants without consent. The affected resident, who is severely cognitively impaired, was unable to recall the incident. Despite the facility's policy to protect residents from abuse, the staff failed to implement adequate interventions to prevent such an occurrence, highlighting a deficiency in ensuring resident safety.
A resident with severe cognitive impairment and diabetes experienced multiple high blood glucose readings over several weeks without timely notification to the physician, leading to hospitalization for diabetic ketoacidosis. Interviews revealed a lack of communication and documentation among staff, and the facility lacked a policy for notifying physicians of changes in resident conditions.
Infection Control Failures During Perineal Care, Wound Care, and Catheter Management
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not use appropriate infection control procedures during perineal care and wound care, did not maintain sanitary conditions for catheter tubing, and did not post Enhanced Barrier Precautions (EBP) signs for residents who had wounds or indwelling catheters. Facility policies reviewed for perineal care, handwashing, gloves, wound care, catheter care, and EBP did not direct staff on several of the practices observed during the survey. For one resident who was always incontinent of bowel and bladder and dependent on staff for toileting and bathing, two CNAs provided perineal care while wearing gloves but did not change gloves when moving from front to back care or from clean to dirty tasks. One CNA stated he or she should have changed gloves when going from front to back, and the other CNA stated he or she should have changed gloves throughout the task. For another resident receiving wound care, an LPN placed gauze in a cup with bare hands, did not perform hand hygiene, and then used the same gloves while touching the resident’s pillow, foot, trash can, urinal, dresser, scissors, bed, and wound care supplies without maintaining a clean barrier or performing hand hygiene between glove changes. For a third resident with wounds and pressure injuries, an LPN performed wound care and perineal care while failing to change gloves between dirty and clean tasks and failing to perform hand hygiene at multiple points during the procedure. The LPN also used the same area of washcloths and wipes repeatedly during perineal care. In addition, the resident’s room did not have EBP signs posted during multiple observations. Similar failures were observed for other residents with catheters and wounds: rooms lacked EBP signage, catheter tubing was observed dragging on the floor, a catheter bag was observed on the floor, and one CNA lifted a catheter bag above waist level, causing urine to backflow into the resident’s bladder before lowering the bed and bag back to the floor. Staff interviews confirmed awareness that catheter tubing should not drag on the floor and that catheters and wounds should be on EBP, while also showing uncertainty about EBP signage.
Failure to Implement Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility policy titled, Antibiotic Stewardship Program (ASP), directed the Infection Preventionist (IP) or designee to audit clinical assessment documentation at the time of antibiotic prescription, review completeness of antibiotic prescribing documentation, and track C. difficile and antibiotic-resistant infections for quarterly reporting. However, the facility's ASP did not contain documentation of an infection/antibiotic control log for January 2025 through June 2025. Review of the Infection/Antibiotic control logs showed repeated missing documentation for antibiotics used in the facility. The July 2025 log showed 20 antibiotics used, with missing documentation for signs and symptoms, site of infection, onset of symptoms, culture status, pathogen identification, and whether the infection was resolved. Similar omissions were found in the August, September, October, November, December 2025, and January 2026 logs, including missing documentation of signs and symptoms, site of infection, culture status, pathogen identification, and infection resolution. During interviews, the IP said he/she gathered and documented antibiotic usage in the log but did not do anything else with the information and did not know what information was required. The DON and ADON stated the IP was responsible for maintaining the infection/antibiotic log and tracking and trending infections and antibiotic use, and the administrator stated she was not aware the antibiotic stewardship program was not being completed.
Failure to Provide Timely Incontinent and Hygiene Care
Penalty
Summary
Facility staff failed to provide appropriate care to meet basic hygiene needs for three dependent residents, including appropriate incontinent care. The report states the facility did not provide a policy addressing toileting or incontinent care for dependent residents. Staff interviews confirmed that incontinent residents should be checked at least every two hours, but the care plans and documentation did not consistently reflect that expectation, and staff described inconsistent follow-through with toileting and hygiene care. Resident #8’s quarterly MDS showed moderately impaired cognition, wheelchair use, substantial to maximal assistance needs for toilet transfer and toilet hygiene, frequent urinary incontinence, and diagnoses including COPD, constipation, type II DM with hyperglycemia, emphysema, diabetic CKD, hypertension, a prosthetic right eye, and schizophrenia. The care plan identified assistance with toileting but did not include interventions for frequency of checking or changing the resident or for agitated behaviors or refusals of care. The TAR did not contain documentation of behaviors or interventions. Observations showed the resident repeatedly sitting in a wheelchair at the dining room table with a strong urine odor, wet pants, and urine puddling on the floor, including while eating lunch. The resident was also observed asking for a brief, and later told staff that no one helped with bathroom use or changing clothing and that being left wet made the resident feel bad. Resident #34’s MDS showed frequent incontinence and dependence for toilet assist and transfer, and the care plan directed peri-care, toilet transfer every two hours, and checking for incontinent episodes with changes every two hours and as needed. The functional assessment showed dependence with all toilet transfers as a two-person assist. Despite this, observations showed the resident sitting in the dining room and activity area with wet pants, strong urine odor, and wet puddles under the wheelchair on multiple occasions. The resident stated being unable to tell when urination occurred, that staff usually changed the resident only after waking, after lunch, and at bedtime, and that staff usually did not ask throughout the day if a change was needed. Staff interviews reflected uncertainty about how often the resident was changed and inconsistent monitoring. Resident #35’s MDS showed the resident required substantial to maximum assistance with perineal hygiene, toileting, and bathing, and the care plan stated the resident had incontinence without sensory awareness, should remain clean and dry after each incontinent episode, and should be assisted with toileting, dressing, and weekly showers. Observations showed the resident sitting in the dining room with wet pants, a large puddle under the chair, strong urine odor, and on another occasion wearing the same clothes from the prior day. The resident stated being embarrassed after accidents, not knowing when incontinence occurred, needing help with clothing and showers, and depending on staff for changing and bathing. A CMT stated being unaware of any incontinent issues with the resident and said he/she had never provided hygiene or perineal care for the resident.
Failure to Complete AMA Documentation
Penalty
Summary
Facility staff failed to meet professional standards when they did not obtain proper Against Medical Advice (AMA) documentation for a resident who left the facility before discharge. The facility’s undated Leaving the Facility against Medical Advice policy directed staff to notify the physician, administrator, and DON, complete the AMA release form, present it for signature in the presence of witnesses, and document the refusal if the resident would not sign. Resident #60’s MDS dated 12/10/25 showed the resident was cognitively intact, did not exhibit behaviors toward others, and did not refuse care. Nurse’s notes dated 12/11/25 documented that the resident was upset about being at the facility, had clothes packed on the bed, and later left against medical advice with a family member; the physician and administrator were notified shortly afterward. Review of the electronic medical record showed no documentation that an AMA release form was completed. During interviews, the SSD said there was no documentation that an AMA form was filled out and that if a resident refuses to sign, staff should note that on the form. The DON said an AMA form should have been completed but was not, and the administrator said the AMA form should have been followed and filled out when the resident wanted to leave AMA.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication error rates were not maintained below 5%, as surveyors observed 3 errors in 34 medication administration opportunities, resulting in a 9.68% error rate and affecting one sampled resident. Facility policies reviewed did not include a definition of a medication error, although they directed staff to report medication errors immediately to the physician, DON, and administrator and required verification of physician orders before administering medications. For Resident #24, the physician order sheet did not include an order to crush medications. During observation, a CMT administered nine of twelve pills, returned to the medication cart, then crushed the remaining three pills before giving them to the resident. The CMT stated the resident had trouble swallowing and that he/she thought there was an order to crush medications as needed, but acknowledged the medications should not have been crushed without an order. The DON and administrator both stated staff are expected to follow physician orders, not crush medications without an order, and notify the charge nurse, DON, physician, and/or pharmacy if a medication error occurs; both said they were not made aware of any medication errors during the survey.
Care Plans Not Updated for Contracture, Wounds, and Edema
Penalty
Summary
The facility failed to develop and revise care plans to reflect residents’ current conditions for 3 of 14 sampled residents. The report states that the interdisciplinary care plan team is responsible for periodic review and updating of care plans when a resident has a significant change, at least quarterly, and when changes occur that affect care. However, staff did not include current care interventions for the identified residents’ contractures, wounds, or edema, despite those conditions being documented in assessments, wound notes, orders, and observations. For Resident #1, the 02/06/26 quarterly MDS showed paraplegia, monoplegia of the right dominant upper limb, and dependence for toileting and bathing, but the 02/10/26 care plan did not include documentation or interventions for the resident’s contracture. The resident was observed on 02/24/26, 02/25/26, and 02/26/26 with the right hand contracted. During interviews, the care plan coordinator said contracture interventions should be on the care plan and was not aware the contracture was omitted; an LPN stated the resident had a right-hand contracture and expected an order and care plan interventions; the administrator also said the contracture should have been addressed on the care plan. For Resident #2, the comprehensive MDS showed moderate cognitive impairment and a pressure injury, and the wound care note dated 02/02/26 documented wounds to the right sacrum, left lateral foot, left lateral foot near the 5th digit, and right heel. The 12/09/26 care plan did not contain interventions for the wounds or wound prevention. For Resident #23, the comprehensive MDS showed moderate cognitive impairment, risk for pressure ulcer/injury, peripheral vascular disease, and chronic venous insufficiency. The 01/09/26 care plan did not address lower leg edema or include interventions, even though the POS dated 02/18/26 included wound care to the left calf and use of tubi-grip and a gel foam cushion. The resident was repeatedly observed with bilateral swollen and red legs, and staff interviews confirmed that edema and wound-related interventions should have been included on the care plan.
Facility Assessment Not Updated Annually
Penalty
Summary
Facility staff failed to update the Facility Assessment at least annually. Review of the Facility's Assessment, dated 12/04/24, showed there was no documentation that the assessment was reviewed for 2025. The facility census was 53.1. During interview, the administrator said she did not know why the facility assessment had not been reviewed and updated since 2024 and stated she was aware the assessment needs to be completed at least annually. The DON stated he/she was not aware the facility assessment had not been updated since 2024 and said the administrator would be responsible and he/she was not familiar with the facility assessment process.
Failure to Provide and Document Assistance with Showers for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living, specifically showers, for six residents who required such support. Review of facility records and interviews revealed that these residents, many of whom had moderate to severe cognitive impairment and required substantial to total assistance for personal hygiene and bathing, did not consistently receive showers as care planned or as per their preferences. Documentation in the electronic medical record (EMR) was often missing, with several residents going weeks without a documented shower or any record of refusal, despite their care plans indicating a need for regular assistance. Observations on the survey date showed multiple residents with greasy, unkempt hair, and in some cases, soiled clothing, indicating a lack of basic hygiene care. Interviews with the affected residents confirmed that they had not received showers for extended periods, with some expressing feelings of discomfort and uncleanliness. Residents reported that staff were supposed to assist them with showers at least once or twice per week, but this was not occurring, and some residents attempted to clean themselves with washcloths due to the lack of assistance. Staff interviews revealed that the designated shower aide was unable to complete all required showers due to time constraints and staffing shortages, particularly for residents needing two-person assistance. Staff also admitted to not always documenting showers or refusals in the EMR when busy. The facility lacked a specific shower policy, and leadership acknowledged that they had not recently reviewed shower documentation, relying instead on visual monitoring and verbal direction to staff. These actions and inactions led to a failure to meet the basic hygiene needs of dependent residents.
Failure to Document and Obtain Orders for New Wounds
Penalty
Summary
Facility staff failed to meet professional standards of care by not documenting assessments of new wounds and not obtaining timely treatment orders from a physician for a resident with multiple pre-existing wounds. The resident, who had severe cognitive impairment, was at risk for pressure ulcers, had one or more unhealed pressure ulcers, and was receiving hospice care. The facility's policies required specific physician orders for wound treatments and mandated that nurses provide treatment as ordered and implement preventive measures. On review, staff documented the presence of new wounds, including a deep tissue injury to the left medial knee and a scabbed area on the right lower leg, but did not document a full assessment or obtain physician orders for these new wounds. The Physician's Order Sheet and Treatment Administration Record for the relevant period did not contain documentation of wound treatment orders or evidence that treatments were provided for the new wounds. Progress notes also lacked documentation of assessment or interventions for these wounds. Interviews with staff revealed that while some interventions were performed, such as applying skin prep and instructing aides to float the resident's heels, these actions were not properly documented. The DON acknowledged that assessments and documentation were incomplete, and the physician confirmed that staff should have assessed and obtained treatment orders for new wounds. The lack of documentation and failure to obtain timely orders constituted a deficiency in meeting professional standards of care for wound management.
Failure to Arrange Timely Dental Care for Resident with Ongoing Tooth Pain
Penalty
Summary
Facility staff failed to ensure that a resident with moderate cognitive impairment and a history of mouth or facial pain received timely assistance in scheduling a dental appointment after reporting broken teeth and intermittent toothache. The resident's care plan indicated the presence of missing or broken teeth and a need for staff assistance with oral care. Despite multiple documented complaints of tooth pain, requests for pain medication, and visible swelling of the face, there was no evidence in the progress notes that staff attempted to schedule a dental appointment for the resident during the review period. Interviews with facility staff revealed that the social worker, who was responsible for arranging dental appointments, was aware of the resident's dental complaints for about a month but had not met with the resident or attempted to schedule an appointment. The DON and administrator both confirmed that the social worker was responsible for this task and expressed that an attempt to schedule a dental appointment should have been made. The facility also lacked a policy for dental care and services, and the resident's physician expected staff to arrange for dental care following reports of tooth pain.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report identifies a deficiency related to the facility's inability to ensure residents were safeguarded from these forms of mistreatment. Specific actions or inactions leading to the deficiency, as well as details about the residents involved or their conditions at the time, are not provided in the report. No further factual observations or events are described beyond the stated failure to protect residents from abuse and neglect.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of abuse involving one resident with severe cognitive impairment within the required two-hour timeframe to the administrator and the Department of Health and Senior Services (DHSS). The resident was found with a black eye and bruising to the shoulders, and staff documented that the resident stated someone had hit them. Although the physician and Director of Nursing (DON) were notified, there was no documentation that the allegation was reported to DHSS as required by facility policy and federal regulations. Interviews revealed that an LPN informed the DON about the resident's injuries and the resident's statement, and specifically asked if the incident was reportable to the state. The DON responded that it was not reportable and planned to speak with the resident. Further interviews with nursing staff and the administrator confirmed that the facility's policy is to report all allegations of abuse within two hours, but the incident was not reported because the DON and administrator claimed they were not made aware of the abuse allegations documented in the nurse's notes. As a result, the required notification to the state agency did not occur.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an alleged incident of resident-to-resident abuse involving a resident with severe cognitive impairment. According to the facility's Abuse and Neglect policy, any reported incident of abuse requires immediate investigation by the administrator or designee, including interviews with the resident, roommates, other residents, staff, and witnesses, as well as documentation of injuries and environmental factors. However, when staff documented that a resident had a black eye and bruising to the shoulders and that the resident stated someone hit them, there was no evidence in the nurse's notes or other records that an investigation was initiated or completed. Interviews with staff revealed that the LPN reported the injuries and the resident's statement to the DON, but the DON did not conduct a formal investigation, citing the resident's history of self-injury as the reason. The administrator confirmed that allegations of abuse should be reported and investigated but stated that in this case, the allegations were not investigated or reported to the state because they had not been formally reported to the DON or administrator. The lack of investigation and documentation was contrary to the facility's policy and regulatory requirements.
Failure to Update Care Plan for Resident Behavioral Changes
Penalty
Summary
Facility staff failed to update the comprehensive care plan for a resident with documented behavioral issues, despite multiple incidents of physical and verbal aggression towards other residents. The resident, assessed as having moderate cognitive impairment, exhibited behaviors such as shoving, making threats, and physically assaulting peers, as recorded in nurse's notes over several months. However, the care plan did not reflect these behaviors or include interventions to guide staff response, contrary to the facility's policy requiring care plans to be revised with changes in a resident's condition. Interviews with facility staff, including a CNA, RN, MDS Coordinator, DON, and the administrator, confirmed that behavioral issues should be documented in the care plan and that interventions should be included. The MDS Coordinator acknowledged responsibility for updating care plans and was unsure why the resident's behaviors were not included. The DON and administrator also stated that such behaviors and interventions should have been care planned, but could not provide a specific reason for the omission, suggesting it may not have been reported to the MDS Coordinator.
Failure to Prevent Elopement and Unauthorized Vehicle Use by Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide adequate protective oversight for a cognitively impaired resident with a known history of elopement, wandering, and exit-seeking behaviors. Despite multiple documented incidents where the resident attempted or succeeded in leaving the facility, staff did not update the resident's care plan to include interventions for elopement or exit-seeking. Additionally, required elopement/wandering assessments were not completed on several occasions, and the resident continued to exhibit wandering and exit-seeking behaviors as documented in nurses' notes. On the day of the incident, the resident was able to exit the facility without staff awareness, access the facility's transport van, and drive it approximately nine miles away. The van keys had been left inside the vehicle by the transport driver, which enabled the resident to operate the van. Staff were unaware of the resident's absence until contacted by the local sheriff's office, who had found the resident at a residential location. Interviews with staff confirmed that the resident was known for exit-seeking and that the van keys had been left in the vehicle due to oversight. The facility's elopement policy required staff to conduct thorough searches, notify appropriate personnel, and complete timely assessments, but these procedures were not followed in this case. The resident's care plan and risk assessments were not updated after previous incidents, and staff failed to provide the necessary supervision and environmental controls to prevent the resident's elopement and subsequent unauthorized use of the facility vehicle.
Failure to Complete and Accurately Document Elopement Assessments
Penalty
Summary
Facility staff failed to accurately complete elopement assessments for a resident who was identified as wandering daily and exhibiting exit-seeking behaviors. The resident was cognitively impaired, suffered from delirium, and was documented in nurses' notes as frequently wandering the facility, approaching exit doors, and attempting to get out. Despite these behaviors, the initial elopement assessment inaccurately scored the resident as low risk, and subsequent required assessments were left incomplete. The facility's elopement policy did not provide guidance on how to complete these assessments. Interviews revealed confusion among staff regarding responsibility for completing elopement assessments, with the DON and MDS/Assessment coordinator providing conflicting accounts of their roles. The MDS/Assessment coordinator stated that assessments may have been overlooked, while the DON acknowledged that assessments were either inaccurate or not completed as required. Corporate oversight processes also failed to identify the missing assessments, contributing to the deficiency.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility staff failed to adhere to proper medication storage and labeling protocols in one of two medication storage rooms and two of three medication storage carts. During an observation, expired intravenous caps and a bottle of Liquid Protein were found in the 300/400 hall medication storage room. Additionally, loose tablets and capsules were discovered in the medication carts on both the 300/400 and 100 halls. These findings indicate a lack of compliance with the facility's policy, which mandates that discontinued, outdated, or deteriorated drugs must not be retained and should be returned to the issuing pharmacy or destroyed. Interviews with facility staff revealed a lack of consistent monitoring and accountability for medication storage. A Certified Medication Technician (CMT) admitted to not checking the carts daily due to returning from vacation, while a Registered Nurse (RN) and the Director of Nursing acknowledged that medication rooms and carts should be checked at least monthly. The Director of Nursing and the facility administrator both stated that nursing staff are responsible for ensuring the proper disposal of out-of-date or loose medications, but ultimately, they are accountable for ensuring these tasks are completed. This deficiency highlights a breakdown in the facility's medication management processes and staff responsibilities.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which was designed to prevent the transmission of multidrug-resistant organisms and protect residents with chronic wounds and indwelling devices. The policy required the use of gloves and gowns during high-contact care activities for residents with wounds or indwelling medical devices, such as feeding tubes. However, observations revealed that staff did not post signage or provide personal protective equipment (PPE) outside the rooms of residents who required EBP, including two residents with wounds and one with a gastrostomy tube. Resident #13, who was cognitively intact and had unhealed stage III and IV pressure wounds, did not have EBP signage or PPE outside their room. Staff, including a registered nurse, failed to wear gowns while providing wound care. Similarly, Resident #52, who was cognitively impaired and had a diabetic ulcer, also lacked EBP signage and PPE, and staff did not wear gowns during care. Resident #60, who was cognitively intact and had a feeding tube, also did not have EBP signage or PPE, and staff did not wear gowns during care activities. Interviews with staff, including a registered nurse and a certified nurse aide, revealed a lack of awareness and understanding of the EBP policy. The Director of Nursing (DON) and the facility administrator indicated that the policy was not fully implemented due to concerns about resident dignity and a lack of clarity on who was responsible for oversight. The DON mentioned that the decision to place residents on precautions was made by the charge nurse, but there was no clear system to notify staff of residents requiring EBP.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in two residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Resident #21 experienced a weight loss of 8.97% over three months and 12.68% over six months. Despite recommendations from the Registered Dietician (RD) to monitor weekly weights and add supplements, these were not communicated to the physician, nor were they implemented. The resident's care plan and dietary card did not reflect the RD's recommendations, and staff interviews revealed a lack of awareness regarding the need for supplements and monitoring of meal intake. Similarly, Resident #61, who was severely cognitively impaired, showed a downward trend in weight since admission. The RD recommended adding a house supplement twice daily due to inadequate food intake, but this was not communicated to the physician or documented in the resident's medical records. Interviews with staff indicated a lack of awareness of the resident's weight loss and the RD's recommendations, with no supplements being provided. The deficiency was further compounded by systemic issues within the facility, including the absence of a policy addressing RD recommendations and weight monitoring. The Director of Nursing (DON) and other staff members were unaware of the RD's recommendations not being implemented, and the MDS Coordinator was not informed of significant weight loss during prior admissions. The facility's failure to communicate and act on RD recommendations and significant weight changes led to the deficiency in maintaining residents' health through adequate nutrition.
Failure to Establish Dialysis Communication and Agreement
Penalty
Summary
The facility failed to establish and maintain an agreement and ongoing communication with a dialysis facility for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's dialysis policy, dated March 2015, outlined the need for communication between the facility and the dialysis unit, including sending a Dialysis Communication record with the resident on each visit. However, the facility did not have a dialysis agreement in place, and there was no communication record maintained in the resident's medical record. Interviews with the resident and staff confirmed that no paperwork was sent with the resident on dialysis days, and the facility had not provided any specific training on dialysis or renal disease. The resident, who was cognitively intact and diagnosed with ESRD, was admitted to the facility and had a physician's order for dialysis three times a week at an outside facility. Despite this, the resident's care plan lacked guidance on communication with the dialysis facility. Interviews with the facility's administrator, DON, and RN revealed a lack of awareness and responsibility regarding the need for a dialysis agreement and communication process. The dialysis center's Nurse Manager also confirmed the absence of an agreement and noted that communication reports are typically sent by facilities to aid in resident care, but this process was not being followed.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to implement necessary interventions to protect a resident from sexual abuse by another resident. Resident #2, who has a history of behavioral episodes due to cognitive changes, was observed by a family member with their hand down Resident #1's pants without consent. Resident #1, who is severely cognitively impaired and dependent on staff for daily activities, was unable to recall the incident. The facility's policy mandates that residents be free from abuse, but this incident indicates a failure to uphold that standard. Resident #1's care plan emphasized the need to keep the resident free from harm, yet the incident occurred in a public area, the main dining room, where Resident #2 was able to approach and engage in inappropriate behavior. Despite Resident #2's history of cognitive issues and a previous similar allegation at another facility, the staff did not have adequate measures in place to prevent such an incident. The incident was reported to the Director of Nursing and the Administrator shortly after it occurred, and the physician and family were notified. Resident #2's care plan was updated following the incident to address the inappropriate behavior, but prior to the event, there were no specific interventions to manage potential sexual behaviors. The facility's investigation revealed that neither resident could recall the incident, and the Director of Nursing was unaware of any prior sexual behaviors exhibited by Resident #2. The administrator acknowledged awareness of a similar past allegation but did not know the outcome, indicating a possible gap in communication or follow-up regarding Resident #2's behavioral history.
Failure to Notify Physician of High Blood Glucose Levels
Penalty
Summary
Facility staff failed to notify a resident's physician of critically high blood glucose levels, resulting in the resident being admitted to the hospital for diabetic ketoacidosis. The resident, who was severely cognitively impaired and completely dependent on staff for daily activities, had multiple blood glucose readings over 400 mg/dL over a period of several weeks. Despite these high readings, there was no documentation that the physician was notified until the resident's condition became critical, leading to hospitalization. Interviews with facility staff, including the Director of Nursing (DON), Certified Medication Technician (CMT), and Licensed Practical Nurse (LPN), revealed a lack of communication and documentation regarding the notification of the physician. The facility did not have a policy directing staff on when to notify the physician of changes in resident conditions. Staff members assumed that the physician was being notified, but this was not the case, particularly on days when the resident had multiple high glucose readings. The DON and administrator acknowledged the expectation to notify the physician of significant changes, but the failure to do so was not explained.
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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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