Estates Of Perryville, Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Perryville, Missouri.
- Location
- 430 North West Street, Perryville, Missouri 63775
- CMS Provider Number
- 265704
- Inspections on file
- 33
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 16 (2 serious)
Citation history
Health deficiencies cited at Estates Of Perryville, Llc, The during CMS and state inspections, most recent first.
Failure to inform residents of risks and benefits before psychotropic medications were started. The facility had no documentation of consent or education for multiple residents receiving antipsychotics, antidepressants, antiseizure medications used as mood stabilizers, and antianxiety medications. Residents had diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, dementia, depression, anxiety, PTSD, and other behavioral or neurologic conditions. One resident said he/she did not recall staff explaining the risks and benefits, and an LPN and the DON said they expected residents and/or representatives to be informed.
The facility failed to accurately code MDS assessments for three residents. One resident with atrial fibrillation had an order for apixaban, but the MDS showed no anticoagulant and routine antiplatelet use; another resident with OSA and a CPAP order was not coded for non-invasive mechanical ventilation; and a third resident was coded as receiving hospice despite no hospice order in the record. The MDS Coordinator, Administrator, and DON stated the MDS should reflect the resident's current condition at the time of assessment.
The facility failed to include specific goals and interventions in the care plans for two residents. One resident with dementia, bipolar disorder, MDD, asthma, and a history of self-harm/suicide attempts had no care plan details for those conditions, and staff interviewed were unaware of the resident’s history or interventions. Another resident with obstructive sleep apnea had no care plan address for CPAP use at bedtime.
Physician Orders Not Followed for Blood Pressure Medications: Staff failed to follow ordered BP parameters when giving or withholding antihypertensive medications for multiple residents. MAR review showed repeated incorrect administration or withholding of clonidine, losartan, metoprolol, lisinopril, propranolol, and atenolol, and staff interviews showed inconsistent understanding of when BP meds should be held versus administered based on the resident-specific orders.
Medication administration errors exceeded the 5% threshold when 2 errors were found in 36 opportunities. A CMT withheld two antihypertensive medications from two residents even though each resident’s BP was within the physician’s hold parameters; the CMT said the meds were held because the BP was too low and later stated a personal threshold of 135/80 was used instead of the ordered parameters. The DON stated meds should be given as ordered and held only when outside the physician’s parameters.
Food was not consistently served at safe and appetizing temperatures for four sampled residents. Residents reported cold, undercooked, or poor-tasting meals, and observations found tray delivery practices that included an uncovered, unheated cart on one hall and food temperatures on a breakfast test tray that were below the facility’s hot-food standard. The Dietary Manager acknowledged resident complaints that food was not hot enough, and the DON and Administrator stated meals should be served at safe and appetizing temperatures.
A resident, who was their own responsible party and had no cognitive impairment, was restricted from taking an independent LOA for two weeks following concerns about unsafe behaviors and returning intoxicated. The restriction was ordered by a physician, but the care plan did not address the LOA restriction or alcohol use, and facility policies did not clarify procedures for such restrictions. Staff interviews confirmed the restriction was due to safety concerns, and the resident expressed that their rights were being infringed.
A resident with a history of suicidal ideation and behavioral health issues exited a secured unit undetected after staff failed to follow the facility's rounding policy requiring hourly visual checks. The resident was missing for about 12 hours and attempted suicide while away, with staff documentation showing rounds were not properly conducted.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A resident with multiple mental health diagnoses became agitated after being denied a cigarette outside of scheduled times. Despite staff awareness of the resident's behavioral triggers, no de-escalation strategies or alternative interventions were used. The situation escalated when the resident grabbed a CNA, leading another CNA to strike the resident in the face, resulting in injury. Staff interviews indicated a lack of formal mental health training and absence of documented interventions for managing such behaviors.
A resident with diagnoses of PTSD, major depressive disorder, TBI, Alzheimer's, and paranoid schizophrenia did not have a Level I or Level II PASRR screening documented in their record. The facility also lacked a policy for PASRR screenings, and although the care plan referenced a completed PASRR, the actual documentation was not available.
A resident with PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's did not receive trauma-informed or culturally competent care, as the facility lacked a policy and failed to document or implement supportive interventions for managing the resident's known behavioral triggers. Staff were aware of the triggers but had not received formal training or guidance on de-escalation strategies.
A resident with multiple mental health diagnoses became agitated after being denied requests to smoke and have a soda, leading to a physical altercation with staff. Facility staff, including agency CNAs and an RN, did not implement de-escalation interventions or offer alternatives, despite being aware of the resident's triggers. Staff interviews confirmed a lack of formal behavioral health or de-escalation training, and there was no documentation of required behavior monitoring or interventions in the care plan.
A resident with severe mental illness, including PTSD and Alzheimer's, became agitated after being denied requests to smoke and have a soda. Staff, including agency personnel, did not attempt de-escalation or offer alternatives, despite being aware of the resident's triggers. The situation escalated to physical aggression, with a CNA striking the resident. The facility lacked documentation of behavior monitoring, a behavioral health management policy, and formal staff training on mental health or de-escalation techniques.
A resident with a history of aggression was inadequately supervised and struck another resident in the head, causing injury, while staff failed to intervene or call for help. Later, the injured resident was physically removed from a hallway against their will by being rolled onto a blanket and dragged by an LPN and CNA, resulting in anxiety that required medication. Staff did not follow facility policies for abuse prevention or intervention during these incidents.
The facility did not ensure that staff, including agency personnel, had the necessary competencies and training to manage residents with behavioral health needs, resulting in one resident being physically assaulted by another and later being inappropriately moved by staff using a blanket. Staff failed to implement care plan interventions, and agency staff reported not receiving training or information about the behavioral unit or residents' needs.
The facility's kitchen operations were found deficient due to unsanitary conditions, including dirt, debris, and cockroach infestations. Staff failed to follow hygiene protocols, such as wearing hairnets and changing gloves between tasks, leading to potential cross-contamination. Expired food items and improper food storage were also observed, contributing to the deficiency.
The facility failed to maintain proper infection control practices during peri and wound care, as staff did not adhere to enhanced barrier precautions (EBP) and neglected hand hygiene protocols. Additionally, the facility did not follow tuberculosis (TB) screening and testing protocols, with lapses in timely test readings and further testing for residents with symptoms. These deficiencies highlight significant gaps in the facility's infection prevention and control program.
The facility failed to maintain an effective pest control program, with observations of live and dead cockroaches in the kitchen, dining area, and other locations. Staff interviews confirmed ongoing pest issues despite monthly treatments. The facility's policy aimed to ensure cleanliness and pest prevention, but current measures were inadequate.
The facility failed to maintain a safe and homelike environment, with observations of urine odor, stained and missing ceiling tiles, and exposed wires. Residents expressed concerns about these conditions, and the Maintenance Director and Administrator indicated that repairs were delayed pending a new roof installation.
A resident with a history of aggressive behavior struck two other residents, resulting in a deficiency in resident safety. Despite being under supervision, the resident's actions led to physical abuse incidents, highlighting a lapse in protective measures. The facility's response included separating the residents and updating care plans, but the initial failure to prevent the abuse indicates a deficiency.
The facility failed to notify the ombudsman of all hospital transfers and did not provide written notifications to residents or their representatives. Multiple residents were transferred without proper documentation, and interviews confirmed the lack of written notifications. The facility's policy did not address notifying responsible parties or the ombudsman.
The facility failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers or therapeutic leave. This issue affected multiple residents, with no documentation found in their records. Interviews with staff revealed a lack of adherence to the policy and communication gaps, leading to the deficiency.
The facility failed to complete significant change MDS assessments within 14 days for three residents following their admission to or discharge from hospice services. Despite the policy outlined in the RAI Manual, the assessments were not conducted in the required timeframe. The facility relies on a contracted company for MDS coordination, with the DON and ADON conducting assessments and providing information for completion.
The facility failed to update and revise care plans for six residents, resulting in care plans that did not reflect current medical conditions or orders, such as the presence of an ostomy, use of tobacco pouches, hospice services, dietary changes, and the use of a Foley catheter. Interviews revealed that a contract company, along with Social Services and the DON, is responsible for updates, but the care plans did not accurately reflect the residents' current conditions as expected by the facility's policy.
The facility failed to follow physician's orders for several residents, including missing blood pressure monitoring, lab draws, and weight records. Residents with various diagnoses, such as schizoaffective disorder, diabetes, and Alzheimer's, did not receive prescribed care, including necessary lab tests and catheter changes. The facility's leadership acknowledged the expectation for adherence to physician's orders, indicating a lapse in maintaining care standards.
The facility failed to provide a comprehensive activity program for residents, affecting their physical, mental, and psychosocial well-being. Several residents reported a lack of suitable activities, especially on weekends, and the Activities Director admitted to being behind on updating care plans. The Administrator and DON expected activities to be available for all residents, including those with special needs.
The facility failed to attempt gradual dose reductions (GDR) or document contraindications for two residents on psychotropic medications, potentially preventing them from receiving the lowest effective dosage. Despite recommendations from the pharmacist, there was no physician response or documentation of GDR attempts. Interviews with staff revealed issues in managing medication regimen reviews and GDRs, contributing to the deficiency.
The facility failed to provide palatable, attractive food at safe temperatures, affecting several residents. Observations showed cold food items served above the expected temperature, and there was no food temperature policy or complete logs. Residents expressed dissatisfaction with the food quality, and the Dietary Manager and Administrator acknowledged the expectations for food service standards.
Failure to Inform Residents of Risks and Benefits Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties, in advance, of the risks and benefits of proposed care before starting psychotropic medications for 11 of 20 sampled residents. The report states that no documentation of consent or education regarding risks and benefits was provided for multiple medications, including antipsychotics, antidepressants, antiseizure medications used as mood stabilizers, and antianxiety medications. The facility policy titled, Use of Psychotropic Drugs, reviewed 08/24/24, stated that decisions and rationale would be documented in the medical record. Resident #2 had diagnoses including epilepsy, major depressive disorder, anxiety disorder, impulse disorder, and schizoaffective disorder, and had orders for Risperdal and Zyprexa for schizoaffective disorder. Resident #3 had schizoaffective disorder, major depressive disorder, and generalized anxiety disorder, and had an order for quetiapine. Resident #4 had major depressive disorder, dementia, and bipolar disorder, with orders for bupropion, Zyprexa, and trazodone. For each of these residents, the record lacked documentation that the resident and/or representative was informed of the risks and benefits before the medications were started. Additional residents had similar missing documentation. Resident #6 had schizophrenia, generalized anxiety disorder, and Parkinson’s disease, with orders for haloperidol and Zyprexa. Resident #8 had ADHD, schizophrenia, narcissistic personality disorder, autistic disorder, and bipolar type schizoaffective disorder, with an order for Zyprexa. Resident #13 had schizophrenia, anxiety, and cerebral infarction, with orders for Risperdal, Keppra, and quetiapine. Resident #30 had suicidal ideations, insomnia, and major depressive disorder with psychotic symptoms, with orders for aripiprazole, Remeron, and trazodone; during interview, the resident said he/she did not recall staff explaining the risks and benefits of the medications. Resident #49 had traumatic brain injury, major depressive disorder, anxiety, migraines, PTSD, cerebral infarction, and falls, with orders for Zyprexa, amitriptyline, Lamictal, Zoloft, divalproex, Keppra, and gabapentin. Resident #59 had schizophrenia, mild intellectual disability, intermittent explosive disorder, bipolar disorder, anxiety, visual hallucinations, agitation, and restlessness, with orders for Uzedy, olanzapine, paroxetine, lorazepam, and valproic acid. Resident #73 had depressive type schizoaffective disorder, with orders for haloperidol and Invega. Resident #90 had delusional disorder, bipolar disorder, dementia, and COPD, with orders for divalproex, fluoxetine, and olanzapine; the resident said he/she did not remember anyone reviewing the risks and benefits of the medications.
Inaccurate MDS Coding for Medications, CPAP Use, and Hospice Status
Penalty
Summary
The facility failed to document accurate MDS assessments for three residents. For Resident #11, the medical record showed a diagnosis of atrial fibrillation and an order for apixaban 5 mg by mouth twice daily, with no order for an antiplatelet medication, yet the admission MDS recorded no anticoagulant use and routine use of an antiplatelet. For Resident #13, the medical record showed obstructive sleep apnea and an order for a CPAP machine at bedtime, but the quarterly MDS indicated the resident did not require a non-invasive mechanical ventilator. For Resident #88, the medical record showed no order for hospice, but the annual MDS indicated the resident received hospice. The MDS Coordinator stated the MDS should accurately reflect the resident's current condition at the time of assessment and said Resident #13 should have been coded for non-invasive mechanical ventilation, Resident #11 should have been coded correctly for anticoagulant use, and Resident #88 was never on hospice. The Administrator and DON stated they would expect the MDS to accurately reflect the resident's condition at the time of assessment.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to implement a comprehensive care plan with specific interventions tailored to individual needs for two residents. For one resident with diagnoses of dementia, bipolar disorder, major depressive disorder, asthma, and a history of self-harm/suicide attempts, the care plan last revised on 03/02/26 did not address the history of self-harm/suicide attempts, dementia, bipolar disorder, or asthma with specific goals and interventions. During interview, the resident stated he/she had attempted suicide three times in the past. For another resident with obstructive sleep apnea and an order for CPAP at bedtime, the care plan revised on 01/07/26 did not address obstructive sleep apnea or CPAP use. During interviews, a CNA and an LPN stated they did not know about the first resident's past or any interventions in place, and the DON and Administrator stated anything pertinent to a resident's care should be included in the care plan and revised as needed, but at least quarterly.
Physician Orders Not Followed for Blood Pressure Medications
Penalty
Summary
The nursing facility failed to follow physician orders when administering blood pressure medications for five residents. The report states that staff did not consistently review and follow the ordered blood pressure parameters before giving or withholding medications, despite the facility policy requiring RNs, LPNs, and CMTs to review orders prior to administration and to follow the orders as written. For one resident with hypertension, clonidine 0.1 mg ordered four times daily with hold parameters for SBP less than 120 and DBP less than 80 was administered on multiple occasions when the recorded blood pressures were outside the ordered parameters, and one dose was withheld when the blood pressure was within the ordered parameters. The MAR showed 11 incorrect doses out of 72. During interview, an LPN stated that the medication should be given when the blood pressure was inside the ordered parameters and withheld when it was outside the ordered parameters. For another resident with congestive heart failure and essential hypertension, losartan 25 mg daily and metoprolol 25 mg twice daily were repeatedly withheld when the recorded blood pressures were within the ordered hold parameters of SBP less than 90 or DBP less than 60, and one dose was administered when the blood pressure was 94/69. The MAR showed 45 incorrect doses out of 302. For a third resident with hypertension, lisinopril 20 mg daily was withheld on numerous occasions when the recorded blood pressures were above the ordered hold parameters of SBP less than 90 or DBP less than 60, totaling 27 incorrect doses out of 70. For a fourth resident, propranolol was withheld on multiple occasions when the recorded blood pressures did not meet the hold criteria, and one dose was administered when the blood pressure was 89/65; the MAR showed 21 incorrect doses out of 202. For a fifth resident, atenolol was repeatedly withheld when the recorded blood pressures were above the ordered hold parameters, totaling 31 incorrect doses out of 100. Staff interviews reflected inconsistent understanding of blood pressure medication parameters, with one CMT stating blood pressure medications should not be given if SBP was less than 135 or DBP was less than 80, while others stated medications should be held only when outside the ordered parameters.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration. Surveyors observed 36 medication administration opportunities and identified 2 errors, resulting in an error rate of 5.56% that affected two residents out of six sampled. The facility policy stated that medications must be administered as ordered, vital signs must be checked or verified before administration, and if a medication is withheld, the reason must be documented. For one resident, the POS required blood pressure monitoring before antihypertensive administration and to hold the medication only if systolic blood pressure was less than 90 or diastolic was less than 60; the resident’s blood pressure was 134/83, but the CMT did not administer losartan and said it was withheld because the blood pressure was too low. For a second resident, the POS also required blood pressure monitoring with the same hold parameters; the resident’s blood pressure was 130/76, but the CMT did not administer atenolol and stated it was withheld because the blood pressure was too low. The CMT later said blood pressure medications would be held if systolic was less than 135 or diastolic was less than 80 and also considered whether the resident was active or a smoker. The DON stated medications should be given as ordered and held only when outside the physician’s parameters, and the Administrator stated the facility expected a medication error rate of less than 5%.
Food Served at Unsafe and Unappetizing Temperatures
Penalty
Summary
Food and drink were not consistently provided at palatable, attractive, and safe appetizing temperatures for four sampled residents. The facility was cited for failing to serve hot food at the required temperature of at least 140 degrees Fahrenheit, and the issue was identified through observation, interview, and record review. The facility policy titled Food Temperature Control, dated February 2024, required potentially hazardous foods to be stored, prepared, held, and served at proper temperatures, with temperatures monitored and documented. Resident Council Minutes from 12/30/25, 01/27/26, and 02/24/26 documented complaints about overcooked food, disliked menus, and meals served late, but no complaints about cold food were recorded. During interviews, Residents #73, #57, #7, and #25 each reported that food was not good, cold, undercooked, or often cold when it should be hot. Observations showed trays being delivered on an uncovered and unheated rolling cart to D Hall and on a closed and heated rolling cart to C Hall, with insulated plate covers on each plate. A breakfast meal test tray on the heated cart showed two poached eggs at 94 F and oatmeal at 110 F. The Dietary Manager stated residents had complained that food was not hot enough, that the complaints were not documented in the February 2026 Resident Council minutes, and that fries and tater tots cooled off quickly on hall trays. The DON and Administrator stated they would expect food to be served at safe and appetizing temperatures.
Failure to Honor Resident's Right to Self-Determination During LOA Restriction
Penalty
Summary
The facility failed to honor a resident's right to self-determination and a dignified existence by restricting the resident, who was their own responsible party and had no cognitive impairment, from taking an independent leave of absence (LOA) for a two-week period. This restriction was implemented through a physician's order following concerns about the resident's safety during previous LOAs, including reports of returning to the facility intoxicated and engaging in unsafe behaviors while away. The resident's care plan did not address the restriction or the resident's alcohol use, and there was no documentation of law enforcement involvement or consideration of a change in the resident's decision-making status. The facility's policy and admission documents did not specify procedures for restricting LOA for residents who are their own responsible party, nor did they clarify the process for evaluating or communicating such restrictions. Interviews with staff confirmed that the restriction was based on safety concerns, but the resident was not provided with alternative options or a formal process for contesting the restriction. The resident expressed frustration, stating that the restriction infringed on their rights, and there was no evidence of a care plan update or further assessment regarding the resident's ability to safely exercise their rights.
Failure to Provide Adequate Supervision Resulting in Resident Elopement and Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate supervision for a resident assessed as needing 24-hour supervision for safety due to a history of suicidal ideation, aggression, and behavioral health diagnoses. The resident, who had diagnoses including schizoaffective disorder, personality disorder, impulse disorder, major depressive disorder, and anxiety, was independently ambulatory and had a care plan indicating a need for close monitoring due to risks of self-harm and aggression. Despite these documented needs, staff did not follow the facility's rounding policy, which required hourly checks and physically seeing each resident in their rooms. On the night of the incident, the resident exited the secured behavioral unit through a window without staff knowledge and was missing for approximately 12 hours. Staff statements indicated that rounds were documented at various times, but none of the staff physically entered the resident's room to visually confirm their presence after the last observed time at the 8:00 P.M. smoke break. The resident was later found by police at a local store, having spent the night outside and attempted suicide using a piece of glass found at the location. Interviews and record reviews confirmed that staff did not adhere to the facility's policy for making rounds and direct observations, resulting in the resident's undetected elopement and subsequent self-harm. The failure to provide the required supervision and to follow established safety protocols directly led to the resident's ability to leave the facility and attempt suicide while unsupervised.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Physical Abuse of Resident Following Escalation Due to Denied Request
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident by striking them in the face with a closed fist, resulting in an injured eyelid and a broken nose. The incident took place after the resident, who has a history of mental health disorders including major depressive disorder, PTSD, traumatic brain injury, Alzheimer's, and paranoid schizophrenia, became agitated when denied a cigarette outside of scheduled smoking times. The resident's care plan noted a pattern of agitation and aggression when requests were denied, particularly regarding smoking, but did not include documented interventions for managing escalating behaviors. On the day of the incident, the resident requested a cigarette and soda from a nurse, who informed them they would have to wait until the scheduled time. The resident became increasingly agitated, and multiple staff reiterated the denial. The resident then grabbed a CNA by the shirt collar and appeared to push the CNA down the hallway. Another CNA intervened by approaching and striking the resident in the right eye, causing visible injury. The staff did not attempt to de-escalate the situation with alternative options or interventions, despite being aware of the resident's behavioral triggers. Interviews with staff revealed that they had not received formal mental health training prior to working at the facility, and their preparation consisted mainly of reading a training manual. Staff acknowledged the resident's known triggers and aggressive behaviors but did not implement any specific de-escalation techniques or alternative strategies during the incident. The lack of documented behavioral interventions and insufficient staff training contributed to the escalation and subsequent physical abuse of the resident.
Missing PASRR Documentation for Resident with Serious Mental Illness and Intellectual Disability
Penalty
Summary
The facility failed to maintain documentation of a Level I preadmission screening and resident review (PASRR) assessment for a resident with serious mental illness and intellectual disability diagnoses. Record review showed that the resident had diagnoses including post-traumatic stress disorder (PTSD), major depressive disorder, traumatic brain injury (TBI), Alzheimer's disease, and paranoid schizophrenia. Despite these diagnoses, there was no evidence in the resident's medical record of a completed PASRR Level I or Level II screening prior to admission, nor was there a current PASRR assessment available. The care plan referenced a completed PASRR and outlined interventions for managing the resident's mental health needs, but the actual PASRR documentation was not provided by the facility. Additionally, the facility did not have a policy related to PASRR screenings. During an interview, a Central Office Medical Review Unit (COMRU) nurse confirmed that a Level II screening had been completed in the past, but stated that a replacement application would be required since the previous screening was over a year old. The absence of current and accessible PASRR documentation in the resident's record constituted a deficiency in ensuring the resident's behavioral health needs were properly identified and addressed.
Failure to Provide Trauma-Informed and Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident's care plan noted triggers such as not receiving medications on time and being denied smoking, which led to physical and verbal aggression. However, the care plan lacked specific interventions for de-escalation or alternatives to manage these behaviors, and there was no documentation of supportive strategies to help the resident cope with escalating behaviors. Additionally, the facility did not have a policy on trauma-informed care or behavioral health management. Interviews with staff revealed that they were aware of the resident's triggers but had not received formal training on trauma-informed care or specific interventions for managing the resident's behaviors. The DON confirmed knowledge of the resident's triggers but was unaware of any interventions in place on the care plan to address them. The absence of a trauma-informed care policy and lack of documented interventions contributed to the facility's failure to provide care that was trauma-informed and culturally competent for the resident.
Failure to Provide Behavioral Health Training and De-escalation Interventions
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of a resident with complex mental health diagnoses, including PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident had active orders for behavior monitoring and multiple psychotropic medications, but there was no documentation of behavior monitoring being completed. The care plan identified the resident's triggers, such as requests to smoke, and noted a history of physical and verbal aggression when these requests were denied. However, there were no documented interventions in place to prevent escalation, and staff were only instructed to attempt to accommodate the resident's requests. On the day of the incident, the resident became agitated after being denied a request to smoke and have a soda outside of scheduled times. Multiple staff, including agency CNAs and an RN, told the resident to wait, which further increased the resident's agitation. The situation escalated when the resident grabbed a CNA, and another CNA responded by striking the resident in the eye. Staff did not attempt any de-escalation interventions or offer alternative options to address the resident's agitation, despite being aware of the resident's triggers and behavioral history. Interviews with staff revealed that there was no formal behavioral health or de-escalation training provided, especially for agency staff, who were only required to read a manual and sign a sheet without any monitoring or verification. The DON and staff confirmed the lack of mental health training and guidance for managing residents with behavioral health needs. Law enforcement also noted repeated issues at the facility related to staff decisions that aggravated residents with mental health conditions.
Failure to Provide Behavioral Health Services and De-escalation for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe mental illness, including PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident, who is their own responsible party, exhibited agitated and aggressive behaviors when denied requests to smoke and have a soda outside of scheduled times. Staff, including agency personnel, did not attempt to de-escalate the situation or offer alternative options, despite being aware of the resident's triggers. Instead, staff repeatedly told the resident to wait, which further increased agitation, ultimately resulting in the resident physically grabbing a CNA, and the CNA responding by striking the resident in the eye. The facility did not provide documentation of required behavior monitoring, despite physician orders for such monitoring every shift. There were also no documented interventions in the care plan to prevent escalation of behaviors, and the facility lacked a policy on behavioral health management. Staff interviews revealed that there was no formal training on mental health disorders or de-escalation techniques, and agency staff were only required to read a manual without any verification or monitoring of their understanding. The DON and RN involved acknowledged the lack of formal training and the absence of alternative interventions offered during the incident. Law enforcement and the medical director confirmed the incident, with law enforcement noting that staff actions often instigated residents with mental health issues by denying requests, leading to aggressive reactions. The medical director stated that staff should never hit a resident, regardless of the situation. The facility did not provide a PASRR for the resident, and there was no evidence of a behavioral health management policy or adequate staff training to address the needs of residents with mental health disorders.
Failure to Prevent Resident-to-Resident and Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by both another resident and staff. One resident, who had a history of aggression and required one-on-one supervision, became agitated after being denied medication and was inadequately monitored by staff. Despite being assigned a one-on-one aide, staff did not intervene or call for assistance when the resident became agitated and began walking down the hallway. Staff observed from a distance as the agitated resident entered another resident's room and struck the resident in the head, causing a hematoma. Staff admitted to not attempting to de-escalate or physically intervene before the assault occurred, and no Code Gray was called as required by facility policy. Following this incident, the assaulted resident, who had diagnoses including schizoaffective disorder and heart failure, was relocated to another hall. The resident attempted to return to their previous room and, when refusing to leave, sat on the floor. Staff, including an LPN and a CNA, attempted to physically move the resident by rolling them onto a blanket and dragging them through the facility to the new room, despite the resident's resistance. This action caused the resident to become anxious, requiring administration of lorazepam for anxiety shortly after the incident. One staff member expressed concern about the appropriateness of this action but was instructed not to document the event. Interviews with staff and the administrator confirmed that staff were aware of the aggressive resident's history and the need for close supervision, yet failed to take appropriate preventive measures. The administrator acknowledged that staff should have intervened to protect residents and that the physical handling of the resident by staff was inappropriate. The facility's own policies on abuse prevention and resident-to-resident altercations were not followed, as staff did not call for assistance or remain in the area to ensure safety during the incidents.
Failure to Ensure Staff Competency in Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, resulting in two significant incidents involving residents with complex mental health histories. One resident with schizoaffective disorder and a history of aggression, including throwing urine and elopement attempts, was residing on a secured behavioral unit and required close supervision and specific behavioral interventions. Another resident, diagnosed with autistic disorder and schizophrenia, had a documented history of physical and verbal aggression, including striking other residents and staff, and was on one-on-one monitoring due to previous altercations. On one occasion, the resident with a history of aggression became agitated after being denied early medication administration. The assigned staff, including agency and facility employees, failed to implement care plan interventions such as redirection or de-escalation techniques. Instead, one staff member hid in a closet, and others observed from a distance as the agitated resident entered another resident's room and struck them, causing a hematoma. Interviews revealed that staff were either unaware of the care plan interventions or did not attempt to use them, and agency staff reported not receiving training or information about the behavioral unit or residents' needs. In a separate incident, after being relocated for safety, the same resident who had been struck attempted to return to their previous room and refused to leave the hallway, sitting on the floor. Agency staff, lacking training and familiarity with the unit or the resident's history, physically moved the resident by rolling them onto a blanket and dragging them through the facility to another hall. The staff involved did not attempt further redirection or allow the resident time to calm down, and facility leadership acknowledged that agency staff had not received required training or policies for the behavioral unit.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, leading to potential cross-contamination and food-borne illness risks for all residents. Observations revealed significant cleanliness issues, including dirt, debris, and trash on the kitchen floor, black carbon buildup on cooking equipment, and the presence of live cockroaches. Additionally, there were missing knobs on the stove, dented cans in storage, and expired food items, such as an opened container of peanut butter past its expiration date. The facility also lacked a policy regarding food storage. During meal service, staff did not adhere to proper hygiene practices. Dietary aides were observed not wearing hairnets, failing to sanitize hands, and not changing gloves between tasks. They touched dirty surfaces and then handled clean plates and residents' food without proper sanitation. The ice scoop and drink pitchers were improperly handled, touching residents' personal cups, which were used throughout the day. These actions were contrary to the facility's handwashing policy, which emphasized the importance of hand hygiene and glove use. Interviews with staff, including the Dietary Manager and Dietary Aides, confirmed ongoing issues with cockroaches and inadequate pest control measures. Staff acknowledged the need for better hygiene practices, such as changing gloves and sanitizing hands between tasks. The Maintenance Director mentioned a pest control book for tracking issues, but it was not available as the pest control company had taken it. The Administrator and DON expressed expectations for a pest-free environment and adherence to hygiene protocols, but these were not met, contributing to the deficiency.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal and wound care for several residents. Observations revealed that staff did not adhere to enhanced barrier precautions (EBP) as required. For Resident #6, CNAs and an LPN performed peri and wound care without wearing gowns, which are part of the EBP for residents with wounds. Additionally, there was no EBP signage or supplies available near the resident's room, indicating a lack of implementation of these precautions. In another instance, during peri care for Resident #4, CNAs failed to perform hand hygiene before donning gloves and did not change gloves between tasks, leading to potential cross-contamination. The CNAs handled various items in the room with soiled gloves, including the resident's nightstand and personal items, without performing hand hygiene. Similar issues were observed with Resident #66, where CNAs did not change gloves or perform hand hygiene between handling soiled and clean items, further compromising infection control practices. The facility also failed in tuberculosis (TB) screening and testing protocols. Resident #8's first-step TB test was read a day late, and Resident #23, who had a prolonged cough, did not receive further testing or instructions as required. The Director of Nursing acknowledged these lapses, indicating a failure to adhere to the facility's TB testing policy. These deficiencies highlight significant gaps in the facility's infection prevention and control program, particularly in the areas of hand hygiene, use of personal protective equipment, and communicable disease screening.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of live and dead cockroaches in various areas, including the kitchen, dry goods storage room, main dining room serving area, and nursing office. The facility's policy, dated 08/24/24, outlined measures to ensure cleanliness and pest prevention, including daily cleaning, monthly pest control treatments, and maintaining entry points in good repair. However, observations revealed significant pest presence, such as live cockroaches in the oven and on walls, dead cockroaches in the dining area, and mouse droppings in serving counter cabinets. Interviews with staff, including the Dietary Manager, Dietary Aides, and the Maintenance Director, confirmed that cockroaches have been an ongoing issue despite monthly pest control treatments. The Maintenance Director mentioned a pest control book for employees to note pest issues, but it was not available as the pest control company had taken it. The Administrator expressed an expectation for the facility to be free from pests, but the current pest control measures were insufficient to address the ongoing infestation.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by several observations and resident interviews. Observations revealed an overwhelming urine odor in the main entrance common area and numerous brown stains on ceiling tiles near the nurses' station and fire doors on C hall. In the D hall common area, there were missing ceiling tiles with exposed wires, large brown stains on remaining ceiling tiles, and dirt and debris in vented tiles. These conditions were confirmed by resident interviews, with one resident expressing concern about the leaking roof and the use of buckets to catch water, and another resident expressing discomfort with the missing ceiling tiles and exposed wires. The facility's Maintenance Repair Policy outlines procedures for addressing maintenance issues, including a work order log and timelines for addressing routine and emergency work orders. However, the Maintenance Director indicated that ceiling tiles had not been replaced due to an anticipated new roof installation. The Administrator confirmed that a new roof was in process, and ceiling tiles would be replaced afterward. This delay in addressing the maintenance issues contributed to the deficiency, impacting the overall environment for the residents.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, leading to a deficiency in ensuring resident safety. Resident #27, who has a history of schizoaffective disorder and impulse control issues, struck Resident #12 and Resident #96 on separate occasions. Resident #12 was sitting in a hallway when Resident #27, perceiving that Resident #12 was yelling at him, struck him on the right side of the face. This resulted in a scratch mark and significant pain for Resident #12, who was subsequently sent to the hospital for evaluation. Later that day, Resident #27 struck Resident #96 in the face after becoming agitated by Resident #96's behavior, although no injuries were noted for Resident #96. Resident #27's care plan indicated a need for supervision due to behaviors of physical aggression and poor impulse control, yet the incidents occurred despite these precautions. The facility's policy mandates that any suspicion or report of abuse must be communicated to the administration and an investigation initiated. However, the incidents suggest a lapse in effectively managing Resident #27's aggressive behaviors and ensuring the safety of other residents. The facility's response included separating the residents and sending them for medical evaluation, but the initial failure to prevent the abuse indicates a deficiency in the facility's protective measures. The facility's investigation revealed that Resident #27 was placed under 1:1 supervision after the incidents, and care plans were updated. However, the deficiency lies in the fact that the abuse occurred in the first place, highlighting a gap in the facility's ability to prevent such incidents. The report does not mention any corrective actions taken prior to the incidents to address Resident #27's known aggressive behaviors, which could have potentially prevented the abuse of Residents #12 and #96.
Failure to Notify Ombudsman and Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify the ombudsman of all transfers to the hospital and did not provide written notification to residents or their representatives regarding transfers or discharges to a hospital. This deficiency affected ten residents within the sample and two residents outside the sample. The facility's policy on Admission, Transfer, and Discharge did not address the process of notifying responsible parties or the ombudsman about transfer notices. The review of medical records for several residents revealed multiple instances where residents were transferred to the hospital without written notification being provided to their representatives. For example, one resident was transferred to the hospital numerous times throughout the year, yet there was no documentation that their representative was informed in writing at the time of transfer. Additionally, many of these hospital transfers were not included in the monthly list sent to the ombudsman. Interviews with residents' guardians and facility staff confirmed the lack of written notifications. Guardians reported receiving verbal notifications but not written ones. The facility administrator admitted there was no proof of written notifications being sent to responsible parties or the ombudsman. The admissions director mentioned that only residents who were discharged completely or stayed overnight were included in the list sent to the ombudsman, excluding emergency room visits, based on previous guidance from the ombudsman's office.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the bed hold policy at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for nine residents within the sample and three residents outside the sample, indicating a systemic issue. The facility's policy requires that residents or their representatives be notified of the bed hold policy upon admission, at the time of transfer, and during non-covered therapeutic leave. However, documentation was lacking in the medical records of the affected residents, showing no evidence that the required notifications were made. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and Admissions Director, revealed a lack of adherence to the policy. The Administrator admitted to having no proof that bed hold policies were sent to responsible parties. The DON and Administrator expected that all residents discharged, including those for emergency room visits, would have a bed hold/transfer form completed and sent to the responsible party and Ombudsman. However, this expectation was not met, as evidenced by the absence of documentation in the residents' records. Further interviews highlighted communication gaps within the facility. The Admissions Director mentioned that she relies on nurses to notify families, guardians, or public administrators about transfers. Despite having master copies of the Notice of Transfer with the bed hold policy at the nurses' stations, the process of ensuring these forms were filled out and communicated was not effectively managed. This lack of coordination and documentation led to the deficiency identified by the surveyors.
Failure to Complete Timely MDS Assessments for Hospice Admissions and Discharges
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for three residents following their admission to or discharge from hospice services. Resident #33 was admitted to hospice services, but the facility did not complete the required MDS assessment within 14 days of this admission. Similarly, Resident #57 was admitted to and later discharged from hospice services, yet the facility did not complete the necessary MDS assessments within the 14-day timeframe for either event. Resident #113 experienced multiple admissions to and discharges from hospice services, and in each instance, the facility failed to complete the significant change MDS assessments within the required 14 days. The facility's policy, as outlined in the Resident Assessment Instrument (RAI) Manual, mandates that a significant change in status assessment (SCSA) must be performed within 14 days of a resident's admission to or discharge from hospice services. However, the facility did not adhere to this policy for the residents in question. During interviews, the Administrator and Director of Nursing (DON) acknowledged the expectation for MDS assessments to be completed per the RAI Manual. The facility relies on a contracted company for MDS coordination, with the Director of Nursing and Assistant Director of Nursing conducting assessments and providing information to the contracted company for completion.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of six residents out of a sample of 23. The care plans did not reflect current medical conditions or orders, such as the presence of an ostomy for one resident, the use of tobacco pouches and hospice services for another, and the need for hospice services for several others. Additionally, dietary changes and the use of a Foley catheter were not addressed in the care plans of two residents. These omissions indicate a lack of timely updates and revisions to the care plans, which are essential for providing accurate and person-centered care. Interviews with the Corporate Nurse/Infection Preventionist and the facility's Administrator and Director of Nursing revealed that a contract company, along with Social Services and the Director of Nursing, is responsible for updating care plans. However, the care plans were not accurately reflecting the residents' current conditions, as expected by the facility's policy. The facility's policy requires care plans to be reviewed quarterly and updated as needed, but this was not adhered to, leading to deficiencies in the care provided to the residents.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to adhere to physician's orders for several residents, leading to deficiencies in care. Resident #5, diagnosed with schizoaffective and anxiety disorders, had an order for daily blood pressure monitoring starting in August 2024, but there were no documented blood pressures for 102 out of 124 days. Resident #8, with diagnoses including type 2 diabetes and major depressive disorder, was on lithium treatment for ten months without any lab draws for lithium levels, and there were missing monthly weight records for September and October. Resident #15, diagnosed with bipolar disorder and hyperlipidemia, had orders for routine blood tests and monthly vital signs and weights, but the tests were not conducted as scheduled, and there was no weight recorded for October. Resident #20, with type II diabetes and schizophrenia, had orders for Hemoglobin A1C tests every three months, but there were gaps in testing, and no weights were recorded for October. Additionally, there were no orders for necessary lab evaluations despite the resident being on multiple medications. Resident #57, diagnosed with muscle wasting, Alzheimer's disease, and urinary retention, was admitted to hospice without an order, and there was no order to change the Foley catheter, which was observed in use over multiple days. The facility's Administrator and DON acknowledged the expectation for residents to have appropriate orders for treatments and special programs, and for these orders to be followed, highlighting a failure in maintaining professional standards of care.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and physical, mental, and psychosocial well-being of each resident. This deficiency affected several residents, both within and outside the sample, and had the potential to impact all residents in the facility. The facility's activities policy outlined the need for a comprehensive, person-centered activity program, but the implementation was lacking. The activities calendar showed a lack of scheduled activities on weekends, and residents reported that activities were sometimes canceled without replacements. Resident #5, who has schizoaffective disorder and anxiety disorder, reported not attending activities due to blindness and a lack of suitable activities. The resident's care plan did not address activities, and there was a delay in providing books on tape. Resident #8, diagnosed with schizophrenia and borderline personality disorder, mentioned that activities were not provided for an entire week in November due to staff absence, and activities on the locked unit were often inaccessible. Resident #15, with schizoaffective disorder and mild intellectual abilities, expressed that there were no activities for younger residents and nothing to do on weekends. Other residents, such as Resident #67, who is legally blind, and Resident #82, with schizoaffective disorder and borderline personality disorder, also reported a lack of age-appropriate activities and insufficient weekend activities. Resident #102, with schizoaffective disorder and bipolar disorder, and Resident #111, with similar diagnoses, both indicated a lack of engaging activities, leading to isolation and inactivity. The Activities Director acknowledged the absence of activities for residents with special needs and sensory issues and admitted to being behind on updating care plans. The Administrator and DON expected activities to be available for all residents, including those with special needs and on weekends.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) or document contraindications for GDRs for two residents, which could prevent residents from receiving the lowest effective dosage of psychotropic medications. Resident #15, diagnosed with multiple psychiatric disorders, was on several psychotropic medications, including perphenazine, risperidone, sertraline, clonazepam, carbamazepine, and hydroxyzine. Despite the absence of documented behaviors since September 2024, there was no evidence of GDR attempts or contraindications. The pharmacist's recommendations for GDRs were not addressed by the physician, and the facility did not provide a policy regarding GDRs. Resident #20, also diagnosed with psychiatric disorders, was prescribed medications such as paliperidone, lithium, venlafaxine, oxcarbazepine, and trazodone. Similar to Resident #15, there were no documented behaviors since March 2024, and no GDR attempts or contraindications were recorded for venlafaxine and trazodone. The pharmacist's recommendations for GDRs were not responded to by the physician, and the facility failed to provide documentation of the physician's response to the medication regimen review. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), revealed that the process for handling medication regimen reviews and GDRs was not effectively managed. The consultant pharmacist noted a delay in receiving timely physician responses to GDR recommendations, indicating a systemic issue in the facility's medication management process. The lack of timely responses and documentation of GDRs or contraindications contributed to the deficiency identified by the surveyors.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide palatable, attractive food at safe and appetizing temperatures, affecting both sampled and non-sampled residents. Observations during a lunch meal revealed that cold food items, such as macaroni salad, pears, deviled eggs, and tomatoes, were served at temperatures ranging from 51 to 60 degrees Fahrenheit, which is above the expected 41 degrees Fahrenheit or below for cold foods. The facility did not have a food temperature policy in place, and there were no temperature logs provided for October, while the logs for November were incomplete, lacking specific dates. Interviews with residents indicated dissatisfaction with the food quality, with complaints about the food being unappealing, not hot enough, and generally not good. One resident even resorted to ordering meals from outside the facility. The Dietary Manager and the Administrator both acknowledged the expectation for cold foods to be served at 41 degrees or below and for temperature logs to be completed as per regulations, highlighting a failure in maintaining proper food service standards.
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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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