Estates Of St Louis, Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 2115 Kappel Drive, Saint Louis, Missouri 63136
- CMS Provider Number
- 265712
- Inspections on file
- 24
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Estates Of St Louis, Llc, The during CMS and state inspections, most recent first.
The facility failed to report an allegation of abuse to the State Survey Agency within the required two-hour timeframe after a physical altercation between two residents in the smoking area, during which one cognitively intact resident with anxiety and depression pulled another severely cognitively impaired resident to the ground and struck the resident, causing a black and purple discoloration under the eye. Facility policy on abuse reporting did not include the federally required immediate/two-hour reporting timeframe, and although nursing staff notified the ADON and the Administrator and documented the injury, leadership delayed reporting while waiting to personally observe the injury, resulting in the incident being reported to the state several days after it occurred.
The facility did not maintain resident personal funds in a separate account from its operating account and failed to provide timely refunds and monthly Social Security/Medicaid allowances to multiple residents. These actions prevented residents and their financial guardians from managing their financial affairs as required.
A resident with chronic hepatitis C did not receive appropriate follow-up care, as the facility failed to complete a clinical referral or initiate treatment despite documented recommendations and active infection. Staff were unaware of the resident's condition and did not obtain ordered labs, and there was no standard process for reviewing and acting on provider orders.
A resident with moderate cognitive impairment and lung cancer underwent lung surgery without the facility notifying the legal guardian (Public Administrator) in advance, as required by policy. Documentation and staff interviews confirmed that the PA was not informed prior to the procedure, and the lack of communication was attributed to administrative changes and missing documentation. The PA only learned of the surgery after the resident called following the procedure.
The facility failed to maintain cleanliness and proper food storage, affecting all 75 residents. Observations showed a sticky kitchen floor, debris, unsealed food, and mouse droppings in the pantry. Nine baking sheets had carbon build-up, and a mixer was rusty. Staff reported cleaning schedules, but pest issues persisted.
The facility did not follow its TB policy, failing to complete required TB screening tests for 10 employees. The DON and Administrator were unaware of the oversight. Additionally, the facility did not implement its water management plan to control Legionella growth, with the MD confirming the absence of necessary measures and documentation.
The facility failed to maintain a pest-free environment, with live mice and droppings found in the kitchen and residents' rooms. Despite regular pest control visits, residents frequently reported sightings of mice, including in their food and personal spaces. The administration acknowledged the issue, but the problem persisted, exacerbated by a shortage of housekeeping staff and inadequate documentation of pest sightings.
The facility failed to conduct CNA registry checks for two newly hired housekeepers, as required by policy. The BOM/HRM admitted oversight, and the Administrator was unaware of the lapse. The facility had hired at least 45 new employees since the last survey, with a census of 78.
The facility failed to provide written transfer or discharge notices to six residents and their representatives, omitting essential information such as the reason and location of the transfer. Interviews with staff revealed a lack of awareness and adherence to policy, with the Social Services Designee not mailing copies of the forms and the Director of Nursing acknowledging incomplete documentation.
The facility failed to provide bed hold notifications to six residents or their representatives within 24 hours of their hospital transfers. The bed hold forms were either blank, unsigned, or not provided, and staff interviews revealed a lack of awareness regarding the notification process. This oversight increased the potential for residents to be unaware of their right to request a bed hold.
The facility failed to ensure interdisciplinary team participation in care conferences for multiple residents, leading to potential unmet care needs. Despite policy requirements, care plan meetings were often attended only by the Social Services Designee and the resident or their family, with no other IDT members present. Interviews revealed that staff were either not invited or did not attend due to time constraints, highlighting a systemic issue in the care planning process.
The facility failed to issue complete and accurate Medicare Part A beneficiary notices for two residents, omitting essential information such as estimated costs and contact details for appeals. The SNFABN and NOMNC forms were not filled out entirely, and residents or their responsible parties did not make informed choices, as required by facility policy.
A resident with moderate cognitive impairment filed a grievance about visitors and rodents. While the visitor issue was addressed, the rodent concern was unresolved. The Administrator signed the grievance form instead of the resident, contrary to policy, and admitted to not following the grievance procedure.
The facility did not report an alleged physical altercation between two residents with severe cognitive impairments to the State Agency, as required by their policy. The incident involved one resident allegedly punching another, with no visible injuries. The Administrator confirmed the incident was not reported, potentially allowing further altercations.
The facility failed to investigate an alleged altercation between two residents with severe cognitive impairments, as required by their policy. One resident allegedly punched the other, but no visible injuries were noted. The incident was not investigated, potentially placing residents at risk of future altercations.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential inaccuracies in care planning and federal reimbursements. A resident's fall was not recorded, another was incorrectly coded as a smoker, a third was inaccurately diagnosed with schizophrenia, and a fourth's fall was omitted from the MDS. The RCN responsible for MDS completion was unavailable for comment.
A resident with severe cognitive impairment and multiple health issues missed a crucial eye appointment due to transportation failure, and the facility did not reschedule the appointment or follow up on routine eye care. The lack of a formal transportation policy and poor communication among staff led to the deficiency in providing timely vision care.
A resident with severe cognitive impairment was observed smoking without a required smoking apron, contrary to the facility's Smoking Policy. Staff interviews revealed a lack of awareness regarding apron requirements, contributing to the deficiency.
A facility failed to maintain an oxygen concentrator for a resident with dementia, as the filter was found covered with a gray substance. Staff were unaware of the maintenance schedule, and no policy existed for cleaning the concentrator. The DON confirmed the issue, and the RCN noted that nurses should check filters when changing tubing, but this was not documented.
The facility failed to maintain cleanliness and organization in medication rooms, leading to potential pest infestation and missing temperature logs. Observations revealed clutter, expired medications, and unsecured tablets. Staff interviews indicated confusion over cleaning responsibilities, and medication carts contained loose pills, showing inconsistent adherence to cleaning schedules.
A resident with severe cognitive impairment and no natural teeth requested dentures but did not receive timely dental care due to inactive benefits and a lack of follow-up. The facility lacked a formal transportation policy, leading to a breakdown in scheduling the necessary dental appointments.
The facility did not maintain a posting of its current survey results. The Administrator kept survey results in a yellow notebook accessible to residents but was unaware of the requirement to post surveys conducted earlier in the year. The facility's survey notebook only contained results from the previous year, despite multiple complaint investigation surveys occurring earlier in the current year.
The facility did not inform residents about the location or content of survey results. Nine residents were unaware of where to find these results, and the Resident Council Meeting Minutes lacked any discussion on this topic. Interviews revealed that the survey results were stored in a yellow notebook, but this was not communicated to the residents, leading to the deficiency.
A resident with severe cognitive impairment and a history of wandering and aggression was not consistently monitored with 15-minute face checks, leading to multiple altercations with other residents. Despite being placed on these checks, there was no documentation for several months. Staff reported challenges in monitoring due to staffing shortages and the resident's quick movements. The facility's interventions, including medication adjustments and the use of an iPad, were inconsistently applied and documented, contributing to ongoing safety issues.
A resident with Alzheimer's disease and known behaviors was not adequately monitored or provided with personalized interventions, leading to multiple altercations with other residents. Despite being on 15-minute checks, documentation was lacking, and the care plan was not updated to reflect incidents or include effective interventions. Staff interviews revealed inconsistencies in monitoring and a lack of training in managing dementia-related behaviors. The facility acknowledged its inability to meet the resident's needs.
The facility failed to ensure staff accurately documented neurological checks for a resident who experienced a fall, resulting in incomplete records and missing critical assessment details. Interviews revealed confusion among staff regarding the documentation process.
A facility failed to report an allegation that a staff member sold drugs to a resident, leading to the resident's overdose. The Administrator did not notify law enforcement when the resident identified the staff member, believing initial police presence was sufficient. The facility's policies lacked guidance on notifying law enforcement in such cases.
Failure to Timely Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the State Survey Agency within the required two-hour timeframe following a resident-to-resident physical altercation that resulted in injury. Facility policy on Abuse, Neglect and Exploitation, dated 4/8/24, defined abuse and outlined general reporting expectations but did not specify that allegations of abuse must be reported to the State Survey Agency immediately, but not later than two hours after the allegation is made, as required by federal regulations. The facility’s Abuse Prevention Plan stated that anyone could report suspected abuse to the abuse agency hotline and that the licensed nurse should respond to the resident’s needs and notify the Administrator and DON, but again did not include the mandated timeframes. The incident involved two residents. One resident, with no cognitive impairment and diagnoses including anxiety disorder and depression, had a care plan problem related to poor impulse control, hitting another resident, and noncompliance with smoking rules. Nursing documentation on the evening of the incident recorded that this resident struck another resident in the eye after an altercation over a cigarette in the smoking area. In a subsequent interview, this resident stated that the other resident drooled on them and tried to take their cigarette, and that they pulled the other resident to the ground and punched them in the nose. The resident was placed on 15-minute checks for behaviors. The other resident involved had severe cognitive impairment and diagnoses including hypertension, stroke, seizure disorder, anxiety, and depression. Nursing notes documented that this resident walked up on another resident trying to take a cigarette, drooled on the other resident, and was then hit in the eye, resulting in a black and purple discoloration under the left eye orbit. The ADON was notified by the charge nurse about the altercation and was told the injured resident had redness under the left eye, but did not review the notes or see the residents until several days later. The Administrator read the nurse’s notes describing the black eye and chose to wait to see the injury before reporting to the Department of Health and Senior Services. The incident occurred on 2/28/26 but was not reported to DHSS until 3/2/26, exceeding the required two-hour reporting timeframe.
Failure to Timely Disburse Resident Funds and Allowances
Penalty
Summary
The facility failed to ensure that resident personal funds were maintained in an account separate from the facility's operating account. Record review showed that personal funds for nine residents were held in the operating account, totaling $19,065.37, and these funds were not credited to the appropriate accounts until two days after the department began a complaint investigation. The Accounts Receivable Manager confirmed that credit balances were created due to various reasons, such as backpay and surplus adjustments, but acknowledged that the credits were not processed in a timely manner. Additionally, the facility did not provide the required Social Security and/or Medicaid monthly allowance to three residents in a timely manner. These residents did not receive their $50 monthly allowance for two consecutive months, and the funds were not refunded until several months later. The Accounts Receivable Manager was unable to explain why the deposits or Social Security payments were missing for those months. These failures prevented residents or their financial guardians from managing their financial affairs as required.
Failure to Provide Follow-Up Care and Treatment for Chronic Hepatitis C
Penalty
Summary
The facility failed to provide services according to acceptable standards of practice for a resident diagnosed with chronic hepatitis C. Upon admission, the resident had a documented diagnosis of chronic viral hepatitis C, with previous recommendations for follow-up at a hepatitis clinic and coordination with a physician regarding a medication regimen. Despite these recommendations and the presence of active infection as indicated by lab results, there was no evidence in the resident's medical record that a referral to a hepatitis clinic was made or that orders for hepatitis C treatment were initiated. Further review of the resident's care plan and medical records revealed that while the care plan acknowledged the hepatitis C diagnosis and outlined approaches such as administering medications as ordered and monitoring for symptoms, there was no documentation that the necessary labs ordered by the ARNP were obtained. Additionally, subsequent history and physical notes failed to list hepatitis C as an active or past medical concern, and there was no follow-up on abnormal lab findings or the need for hepatitis C treatment. The resident's condition progressed to cirrhosis and hepatocellular carcinoma, as documented in hospital and hepatology clinic records. Interviews with facility staff, including an LPN and the DON, indicated a lack of awareness regarding the resident's hepatitis C status and the required follow-up actions. The DON confirmed that there was no standard procedure for ensuring ARNP and physician orders were consistently reviewed and acted upon, and was unaware of the CDC's updated guidance for hepatitis C testing. The absence of a clear process for order review and follow-up contributed to the failure to provide appropriate care and treatment for the resident's chronic hepatitis C.
Failure to Notify Resident's Legal Guardian Prior to Lung Surgery
Penalty
Summary
The facility failed to ensure that a resident's legal guardian, the Public Administrator (PA), was informed in advance of a significant medical treatment—lung surgery to remove the right upper lobe for cancer. According to the facility's policy, the nurse supervisor or charge nurse is required to notify the resident's family or representative within 24 hours of a significant change in condition or the need for hospital transfer, except in emergencies. Documentation and interviews revealed that the PA was not notified prior to the surgery, and there was no evidence in the resident's progress notes of communication with the PA regarding the surgery. The resident in question had moderate cognitive impairment and diagnoses including COPD, lung cancer, bipolar disorder, and a personality disorder. The care plan specified that the PA should be actively involved in care decisions, including being invited to meetings and contacted about concerns. The last documented contact with the PA's office regarding the resident's lung cancer was for consent to a bronchoscope procedure, with no further communication about the subsequent surgery. The PA's office only became aware of the surgery after the resident personally called them following the procedure. Interviews with facility staff, including the ADON, LPNs, and CMT, confirmed that the responsibility for notifying the PA lay with the charge nurse or DON, but none could confirm that notification occurred. Staff cited changes in administration and lack of documentation as contributing factors. The administrator and DON acknowledged that approval from the PA should have been obtained prior to treatment, and that progress notes should reflect such communication, but were unable to verify that this was done.
Facility Fails to Maintain Cleanliness and Proper Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper storage standards in the kitchen and pantry areas, which had the potential to affect all 75 residents. Observations revealed that the kitchen floor was sticky and littered with debris, including dust, paper, and food particles. The freezer contained unsealed bags of donuts and had a sticky substance on its exterior, while the pantry floor was cluttered with a soda can, plastic bag, and mouse droppings. Additionally, mouse droppings were found in a box of chicken noodle soup and on cans of food, with a baby mouse discovered in a drawer labeled 'Applications.' Further observations noted that nine large baking sheets had a build-up of black carbon, and the large stand mixer had a rusty base and chipped paint. The inside of the microwave contained dried food particles, and a large deep dish baking pan also had black carbon build-up. Interviews with the Dietary Manager and a Dietary Aide revealed that the kitchen was supposed to be cleaned between meal preparations and at the end of each shift. However, the presence of mouse droppings and live mice sightings indicated ongoing pest issues, despite staff signing off on cleaning schedules.
Failure to Implement TB Screening and Water Management Plan
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) policy by not completing the required TB screening tests for 10 employees in a timely manner. The policy mandates a two-step TB test upon hire and an annual one-step test for all employees. However, the review of employee files revealed missing documentation for both the initial two-step and the annual one-step tests for several staff members. Interviews with the Director of Nursing (DON) and the Administrator indicated a lack of awareness regarding the incomplete TB tests, with the DON acknowledging responsibility but unable to explain the oversight. The facility recently hired an Assistant Director of Nursing (ADON) to manage the TB testing process. Additionally, the facility did not implement its water management plan to identify and control the growth of Legionella and other waterborne pathogens. The Maintenance Director (MD) confirmed the absence of text and flow diagrams of the water system and acknowledged that no measures were in place to prevent Legionella growth. The Director of Operations (DO) had previously sent the MD an assessment to complete, which included testing for specific organisms, mapping the water system, and monitoring water temperatures, but it was not completed. This lack of action indicates a failure to validate the effectiveness of control measures as outlined in the facility's water management policy.
Pest Infestation in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of live mice and mouse droppings in both the dietary area and residents' rooms. Observations revealed a live mouse and droppings in the kitchen's dry storage pantry, and multiple residents reported seeing mice in their rooms. The Dietary Manager acknowledged the issue, stating that pest control visits the facility twice a month, but confirmed the presence of droppings in the storage area. Despite the pest control efforts, the problem persisted, with residents frequently reporting sightings of mice. Several residents, including those with cognitive impairments and mental health diagnoses, reported seeing mice in their rooms and common areas. Interviews with residents revealed that they had observed mice in various locations, including near dressers, under beds, and in restrooms. Some residents reported finding mouse droppings on their food, leading them to avoid eating meals prepared by the facility. The facility's pest control logs indicated regular visits by a pest control company, but the issue remained unresolved, with residents continuing to express concerns about the rodent problem. The facility's administration and staff were aware of the rodent issue, with the Administrator acknowledging the problem and the Director of Nursing admitting a lack of documentation on pest sightings. The facility had contracted multiple pest control companies, but the problem persisted, exacerbated by a shortage of housekeeping staff. The Resident Council and Ombudsman also noted ongoing complaints about the rodent issue, with residents expressing dissatisfaction with the facility's efforts to address the problem. Despite attempts to control the rodent population, the facility failed to ensure a pest-free environment, compromising the sanitary conditions and potentially exposing residents to health risks.
Failure to Conduct CNA Registry Checks for New Employees
Penalty
Summary
The facility failed to ensure that newly hired employees were properly screened to rule out the presence of a Federal Indicator on the Certified Nurse Aide (CNA) Registry for two staff members. A review of a sample of 10 employee files revealed that two housekeepers, hired on 10/2/23 and 9/18/24, did not have the required CNA registry checks performed. This oversight occurred despite the facility's policy, which mandates background, reference, and credentials checks for all employees prior to or at the time of employment. During interviews, the Business Office Manager/Human Resource Manager (BOM/HRM) acknowledged responsibility for ensuring CNA registry checks for all employees and admitted that these two employees were overlooked. The Administrator also expressed an expectation that the facility's policy be followed and was unaware that the CNA registry checks had not been completed for these employees. The facility had hired at least 45 new employees since the last survey, and the census at the time was 78.
Failure to Provide Proper Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to six residents and their representatives, as required by policy. The notices were supposed to include the reason for the transfer, the location of the transfer, and information on how to appeal the transfer. This deficiency was identified through a review of records, interviews, and policy review, revealing that the facility did not comply with its own standards for notifying residents, their representatives, and the Ombudsman. For Resident 9, the transfer and discharge documents dated March 28 and July 13 did not include the reason or location of the transfer, and copies were not provided to the resident or their representative. Similarly, Resident 13's transfer document dated August 23 lacked the necessary information and was not shared with the resident or their representative. Resident 28 experienced multiple transfers, and none of the documents for these transfers included the required information or were provided to the resident or their representative. Interviews with facility staff, including the LPN, Social Services Designee (SSD), and Director of Nursing (DON), revealed a lack of awareness and adherence to the policy. The SSD admitted to not mailing copies of the transfer/discharge forms to the residents' representatives and only verbally reporting to the Ombudsman. The DON acknowledged that the forms were not being completed correctly and that the expectation was for the forms to be filled out and copies provided to the residents and their representatives.
Failure to Provide Bed Hold Notifications for Hospitalized Residents
Penalty
Summary
The facility failed to provide bed hold notifications to six residents or their representatives within 24 hours of their emergent transfer to the hospital. This deficiency was identified through a review of records, interviews, and policy review. The facility's policy required that a bed hold notification be given upon admission and at the time of transfer to the hospital, but this was not adhered to. For residents R9, R13, R17, R28, R78, and R129, the bed hold forms were either blank, unsigned, or not provided at all during their hospitalizations. Interviews with the Social Services Designee (SSD) and the Director of Nursing (DON) revealed a lack of awareness and communication regarding the requirement to provide these notifications and obtain necessary signatures. The report highlights specific instances where residents were transferred to the hospital without receiving the required bed hold notifications. For example, R9 was transferred to the hospital multiple times without receiving a completed bed hold form. Similarly, R17 was sent to the emergency department on several occasions without the necessary documentation being completed. The SSD admitted to not sending out copies of the bed hold policy upon transfer, and the DON was unaware of this oversight. This failure to provide proper notification increased the potential for residents to be unaware of their right to request a bed hold, potentially affecting their ability to return to the facility.
Lack of Interdisciplinary Participation in Care Conferences
Penalty
Summary
The facility failed to ensure that all Interdisciplinary Team Members (IDT) participated in quarterly care conferences for 12 of 24 sampled residents. This deficiency was identified through interviews, record reviews, and facility policy reviews. The facility's policy, revised on 08/24/24, mandates that care plan conferences should include the interdisciplinary team, the resident, and the responsible party or guardian. However, the review of care plan meeting notes for several residents revealed that only the Social Services Designee (SSD) and occasionally the resident or their family attended these conferences, with no other IDT members present. For instance, Resident 9, who was readmitted with a primary diagnosis of heart failure, had care plan meetings attended only by the SSD and the resident. Similarly, Resident 12, admitted with hemiplegia and hemiparesis following a stroke, also had care plan meetings attended solely by the SSD and the resident. This pattern was consistent across multiple residents, including those with complex medical conditions such as dementia, chronic obstructive pulmonary disease, Alzheimer's Disease, and schizoaffective disorder, among others. The absence of other IDT members in these meetings indicates a systemic issue in the facility's care planning process. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed a lack of clarity and communication regarding the attendance of IDT members at care conferences. Some staff members reported never being invited to these meetings, while others indicated that they were informed but did not attend due to time constraints or staffing issues. The DON acknowledged that all disciplines should attend care conferences but noted that staff often do not show up despite being notified. This lack of participation from the IDT potentially leaves residents with unmet care needs, as the comprehensive input required for effective care planning is not being utilized.
Failure to Issue Complete Medicare Notices
Penalty
Summary
The facility failed to correctly issue Medicare Part A beneficiaries the CMS-10055 Skilled Nursing Advanced Beneficiary Notice (SNFABN) when residents completed therapy or skilled nursing services. This deficiency was identified for two residents, who were not provided with complete and accurate SNFABN and Notice of Medicare Non-Coverage (NOMNC) documents. The documents lacked essential information such as the estimated cost to continue therapy, contact details for the Medicare contractor, and information for the Quality Improvement Organization (QIO) in case of an appeal. Additionally, the residents or their responsible parties did not make a choice on the SNFABN forms, which were signed without selecting an option. The facility's policy required that these notices be delivered at least two calendar days before Medicare-covered services ended. However, the Social Services Designee and the Director of Operations indicated that the forms were not filled out completely and were not provided in a timely manner. The deficiency was further compounded by the lack of clarity on who was responsible for issuing these forms, as there was a discrepancy between the business office and the Social Services Designee regarding their roles in this process.
Failure to Resolve Resident Grievance Timely
Penalty
Summary
The facility failed to resolve grievances in a timely manner for a resident, identified as R23, who had filed a grievance concerning two issues: the number of visitors in his roommate's room and the rodent population within the facility. While the concern regarding the visitors was addressed by the Administrator, the issue related to the rodent population was not resolved, and the grievance form lacked the resident's signature indicating satisfaction with the resolution. Instead, the form was signed by the Administrator, which was against the facility's grievance policy. The resident, R23, who has a moderate cognitive impairment as indicated by a BIMS score of nine out of 15, expressed that the rodent issue remained unresolved months after the grievance was filed. The Administrator admitted to not following the grievance policy and acknowledged signing the form that should have been signed by the resident. The Social Services Director, initially responsible for handling grievances, was overwhelmed, leading the Administrator to take over the process, yet failing to resolve the resident's concerns adequately.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to timely report an alleged physical altercation between two residents to the State Agency (SA), as required by their policy. The incident involved Resident 13 and Resident 17, both of whom have severe cognitive impairments as indicated by their Brief Interview of Mental Status (BIMS) scores. Resident 17 allegedly punched Resident 13 in the eye on November 30, 2024, but there were no visible injuries reported. Despite the incident, Resident 13 did not recall the altercation and expressed no fear of staff or other residents during an interview conducted on December 18, 2024. The facility's policy mandates immediate reporting of any allegations or suspicions of abuse, neglect, or exploitation to the Administrator and other relevant authorities, including the State Survey and Certification agency. However, the Administrator confirmed during an interview on December 18, 2024, that the incident was not reported to the SA. This oversight had the potential to allow continued resident-to-resident altercations, as the facility did not adhere to its own policy for reporting such incidents.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged altercation between two residents, R13 and R17, which was a violation of their Abuse, Neglect, and Exploitation Policy. The policy mandates that any suspicion of abuse must be communicated to the facility's Administrator or designee, who must then initiate an investigation. This investigation should include interviewing all witnesses separately, obtaining signed and dated witness statements, and documenting the investigation chronologically. However, the Administrator confirmed that the alleged incident between R13 and R17 was not investigated as required. Resident R13, who was admitted with a primary diagnosis of dementia, had a severe cognitive impairment with a BIMS score of three out of 15. Similarly, Resident R17 also had severe cognitive impairment with a BIMS score of five out of 15. According to R17's progress note, R17 allegedly punched R13 in the eye, although there were no visible injuries. During an interview, R13 stated he did not recall the incident and was not afraid of any staff or residents. The lack of investigation into this incident had the potential to place residents at risk of future altercations.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for four residents, leading to potential inaccuracies in federal reimbursements and care planning. Resident 9 was readmitted with a primary diagnosis of heart failure and had a fall on 07/08/24, which was not recorded in the MDS assessment dated 07/13/24. Resident 37, with a primary diagnosis of pulmonary fibrosis, was incorrectly coded as a smoker in the MDS assessment dated 12/04/24, despite a Smoking Safety Evaluation indicating otherwise. The facility's document on residents who smoke did not include Resident 37. Resident 32 was admitted with a diagnosis of schizophrenia, but interviews with the Regional Corporate Nurse (RCN) and Director of Operations (DOR) revealed that the resident did not have this diagnosis. Resident 19, with diagnoses including intellectual disabilities and dementia, had a fall on 01/16/24, which was not reflected in the MDS assessment dated 02/16/24. The Corporate Director of Operations confirmed that the RCN was responsible for completing the MDS, but the RCN was unavailable for an interview.
Failure to Reschedule Missed Eye Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision due to a series of oversights and miscommunications. The resident, who had severe cognitive impairment and multiple diagnoses including diabetes and dementia, missed a crucial eye appointment for retina surgery and cataract surgery because the transportation did not show up. The staff did not reschedule the appointment after it was missed, and there was no follow-up on the resident's routine eye care. The resident's medical records lacked documentation of the missed appointment and any subsequent actions to address the issue. Interviews with facility staff revealed that there was no formal transportation policy, only a protocol that was not effectively followed. The Administrator was unaware of the missed appointment until the day of the interview and acknowledged that the appointment should have been rescheduled immediately. The resident was not listed for an upcoming eye visit due to missing consent forms, further delaying necessary care. The lack of communication and documentation among the interdisciplinary team and transportation staff contributed to the deficiency in providing timely and appropriate vision care for the resident.
Failure to Ensure Resident Wore Smoking Apron
Penalty
Summary
The facility failed to ensure that a resident identified as requiring a smoking apron wore one while smoking, placing the resident at risk for injury. The facility's Smoking Policy mandates that residents who are supervised smokers and require smoking assistance, such as smoking aprons, must have these needs addressed and care planned for preventative measures. The resident in question, who has severe cognitive impairment and is a smoker, was observed smoking without a smoking apron, despite the care plan indicating the need for one. Interviews with facility staff revealed a lack of awareness and clarity regarding the requirement for smoking aprons. A Certified Nurses Aid (CNA) was unsure of the location of the aprons and which residents required them. The Social Services Designee confirmed that the resident should wear an apron during smoking, and the Director of Nursing admitted uncertainty about how staff were informed of the apron requirements. This lack of communication and adherence to policy contributed to the deficiency observed.
Failure to Maintain Oxygen Concentrator
Penalty
Summary
The facility failed to provide proper maintenance for an oxygen concentrator used by a resident with severe cognitive impairment and a primary diagnosis of dementia. The resident was receiving oxygen therapy as part of their care plan due to ineffective gas exchange. During an observation, it was noted that the oxygen concentrator's external filter was covered with a light gray substance, indicating it had not been cleaned. Interviews with facility staff revealed a lack of awareness regarding the maintenance of the oxygen concentrator, and it was unclear when the filter was last cleaned. The Director of Nursing confirmed the presence of the gray substance on the filter and stated that the hospice agency was responsible for the maintenance of the oxygen concentrator. However, the facility did not have a policy in place for the maintenance or cleaning of oxygen concentrators. The Regional Corporate Nurse mentioned that nurses should check the filter when changing the tubing, but this practice was not documented in a formal policy. This oversight had the potential to impact the effectiveness of the oxygen therapy provided to the resident.
Medication Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain the cleanliness and organization of two medication rooms, which could potentially lead to pest infestation. Observations revealed paper dirt, trash debris, and clutter, including personal belongings, on the countertops. The medication refrigerator lacked a current temperature log for December, and previous months' logs were missing. Interviews with the Director of Nursing and staff indicated that Certified Medication Technicians (CMTs) were responsible for cleaning and maintaining temperature logs, but there was confusion and difficulty due to storage space shortages. Additionally, expired medications and syringes were found on the medication cart, and unsecured tablets were observed. Further observations of the medication carts revealed loose pills in various drawers, indicating a lack of regular cleaning and organization. Interviews with staff, including Licensed Practical Nurses (LPNs) and CMTs, showed a lack of awareness regarding cleaning schedules for the medication carts. The Director of Nursing stated that carts should be cleaned daily or at least weekly, but this was not consistently practiced. The presence of loose pills and expired items on the carts highlights the facility's failure to adhere to its policy on medication storage and labeling.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
The facility failed to provide necessary dental care services to a resident who requested dental services. The resident, who has severe cognitive impairment and is fully edentulous, expressed interest in obtaining full dentures. Despite having impressions completed for dentures, the process was halted due to the resident's dental benefits not being active at the time. The resident's benefits became effective in January 2025, but the facility did not schedule a dental appointment to continue the denture process. The deficiency was further compounded by a lack of a formal transportation policy, which led to a breakdown in communication and follow-up. The transportation staff responsible for scheduling appointments was out of work, and interim arrangements failed, resulting in the resident not being placed on the dental appointment list. The facility's administrator acknowledged the oversight and indicated that the dental appointment was being scheduled after the issue was identified.
Failure to Post Current Survey Results
Penalty
Summary
The facility failed to maintain a posting of its current survey results, as required. An interview with the Administrator revealed that the survey results are kept in a yellow notebook accessible to residents. However, the Administrator admitted to only maintaining the state and life safety survey results and was unaware of the requirement to post surveys conducted earlier in the year. A review of the facility's survey notebook showed it only contained the recertification/complaint survey results from the previous year, despite the Missouri Department of Health and Senior Services website indicating multiple complaint investigation surveys had occurred earlier in the current year.
Failure to Inform Residents of Survey Results
Penalty
Summary
The facility failed to inform and review with residents the results of the facility's surveys. During a group meeting, nine residents expressed that they were unaware of the location of the survey results and that these results were never discussed with them. The review of the Resident Council Meeting Minutes, provided by the Activity Director, did not show any discussion of past survey results or their location. This indicates a lack of communication between the facility administration and the residents regarding survey outcomes. Interviews with the Administrator and the Activities Director revealed that the survey results were kept in a yellow notebook outside the copier room, but this information was not communicated to the residents. The Administrator assumed that the residents were informed about the survey results' location during discussions of residents' rights, which was not the case. The Activities Director confirmed that while residents' rights are discussed monthly, the survey results and their location have never been addressed. This oversight led to the residents being uninformed about the survey results, contributing to the deficiency.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure residents were free from physical abuse and did not follow its policies to prevent resident-to-resident abuse. This was evident when staff failed to consistently monitor a resident during 15-minute face checks, an intervention for wandering. This oversight contributed to multiple resident-to-resident altercations, affecting the safety and privacy of other residents on the secured unit. The facility's policies on abuse, neglect, and exploitation, as well as supervision and management of residents with behaviors, were not adequately implemented. The resident involved had a history of severe cognitive impairment, Alzheimer's disease, depression, and anxiety, with documented behaviors of wandering and physical aggression towards others. Despite being placed on 15-minute checks due to these behaviors, there was no documentation of these checks for several months. The resident was involved in multiple altercations with other residents, resulting in injuries and hospital evaluations. The facility's failure to document and consistently perform the 15-minute checks contributed to these incidents. Interviews with staff and the resident's Power of Attorney revealed that the facility's interventions were insufficient and inconsistently applied. Staff reported difficulties in monitoring the resident due to staffing shortages and the resident's quick movements. The facility attempted various interventions, such as medication adjustments and the use of an iPad for engagement, but these were not consistently effective or documented in the resident's care plan. The lack of consistent monitoring and documentation, along with inadequate staffing, contributed to the ongoing safety issues.
Failure to Manage Resident with Dementia Leads to Altercations
Penalty
Summary
The facility failed to ensure a resident with Alzheimer's disease and known behaviors attained or maintained their highest practicable mental and psychosocial well-being. The staff did not provide increased behavioral monitoring or update the resident's care plan with identified triggers, personalized interventions, and meaningful activities focused on the resident's preferences. This failure resulted in a resident-to-resident altercation. The resident had a history of severe cognitive impairment, physical behavioral symptoms directed towards others, and wandering, which were documented in their Minimum Data Set (MDS) assessment. The resident's progress notes indicated multiple incidents of wandering into other residents' rooms, leading to physical altercations. Despite being placed on 15-minute face checks due to wandering, there was no documentation of these checks for several months. The facility's investigation into a resident-to-resident altercation revealed that the resident's care plan was not updated to reflect the incident or include specific interventions such as 1:1 supervision. Interviews with staff and the resident's Power of Attorney (POA) highlighted a lack of communication and effective interventions to manage the resident's behaviors. The facility's policies on supervision and management of residents with behaviors, care planning, and communication documentation were not effectively implemented. Staff interviews revealed inconsistencies in monitoring and documenting the resident's behavior, as well as a lack of training in managing dementia-related behaviors. The facility's attempts to use interventions such as an iPad and signage were not successful, and the resident continued to wander and engage in altercations. The facility acknowledged its inability to meet the resident's needs and was seeking alternative placements for the resident.
Failure to Document Neurological Checks
Penalty
Summary
The facility failed to ensure staff completely and accurately documented neurological checks for a resident who experienced a fall. The facility's Fall Policy mandates that staff perform and document frequent neurological assessments for a minimum of 72 hours following a fall, especially if the fall was unwitnessed or if the resident hit their head. However, the documentation for the resident in question was incomplete, with missing times and lack of documentation for pupil size and reactivity, which are critical components of the neuro checks. The resident, who had severe cognitive impairment and diagnoses including high blood pressure, Alzheimer's Disease, and depression, was found on the floor with a bleeding cut under their right eye. The resident was alert and responsive but was taken to the hospital for further evaluation. Upon return to the facility, the resident's neuro checks were supposed to be documented as per the Fall Policy, but the records showed significant gaps and omissions in the required assessments. Interviews with the facility staff revealed confusion and lack of adherence to the Fall Policy. One LPN admitted to not filling out the neuro check form because the resident was not in the facility at the time, while another LPN stated that they started the neuro checks upon the resident's return from the hospital. The facility's Administrator and Regional Director of Operation acknowledged that the Fall Policy was not followed as written and emphasized the importance of accurate documentation to ensure the resident's stability and to monitor for any changes in condition.
Failure to Report Allegation of Staff Providing Drugs to Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to law enforcement as required. The resident alleged that a Certified Medication Technician (CMT) sold them a pill containing cocaine and Fentanyl, which led to the resident becoming unresponsive and requiring emergency medical intervention. The facility's Administrator did not report this allegation to the police, believing that the initial police presence during the emergency response was sufficient. However, the facility's investigation did not include notifying law enforcement when the resident identified the staff member who provided the drugs. The facility's policies on abuse, neglect, and exploitation did not include guidance on when to notify law enforcement, and the drug and alcohol policy did not address the specific situation of a drug overdose or the involvement of staff in providing illicit substances. The resident, who had a history of psychotic disorder and meth abuse, was found unresponsive in their room and required administration of Narcan by staff before being transported to the hospital by EMS. The resident later disclosed that they had purchased the drugs from the CMT and consumed them, leading to the overdose. During interviews, the Administrator acknowledged that the police should have been notified when the resident provided the staff member's name. The facility's investigation confirmed that the resident tested positive for cocaine and Fentanyl but did not show that law enforcement was notified about the staff member's involvement. The facility's failure to report the allegation to law enforcement as required constitutes a deficiency in their handling of the situation.
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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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