Four Seasons Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sedalia, Missouri.
- Location
- 2800 Highway Tt, Sedalia, Missouri 65301
- CMS Provider Number
- 265149
- Inspections on file
- 35
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Four Seasons Living Center during CMS and state inspections, most recent first.
Staff failed to follow abuse reporting requirements when a cognitively intact resident reported being raped in their sleep and requested hospital evaluation for a rape kit. An LPN reported the allegation to the administrator in the early morning hours and believed it had been reported to the state agency. The administrator confirmed receiving the report but chose not to notify the state, stating that an internal investigation completed within two hours concluded the alleged sexual abuse did not occur, contrary to the policy requiring immediate reporting of all such allegations to the state agency within two hours.
Facility staff did not accurately code psychiatric/mood disorder diagnoses on MDS 3.0 assessments for three cognitively intact residents who had documented bipolar disorder or PTSD in their diagnosis reports and care plans. Although the facility’s policy required accurate and timely completion of MDS sections, the MDS assessments omitted these active psychiatric diagnoses while care plans referenced bipolar disorder, schizophrenia, hallucinations, delusions, and PTSD with interventions. During an interview, the MDS Coordinator stated that active diagnoses under treatment should appear on the MDS but admitted not knowing whether these residents had bipolar disorder or PTSD due to the large resident population.
Staff failed to update care plans after new or increased behaviors, including suicidal ideation and physical aggression. One resident involved in a resident-to-resident altercation with religiously themed statements about not needing medication did not have new interventions added to the care plan despite documentation of the incident. Another resident with depression, assessed as low suicide risk, repeatedly expressed self-harm intent and was found with ligatures around the neck on multiple occasions, yet the care plan lacked guidance for staff on responding to suicidal ideation or self-harm attempts. Additional residents who engaged in physical and verbal altercations were assessed as cognitively intact without behavioral symptoms, and their care plans were not revised to include behavior-related interventions. Interviews with an LPN, the administrator, and the MDS coordinator confirmed that care plans should be updated after such events but highlighted that this was not consistently done.
Staff failed to report an allegation of physical abuse to the state survey agency within the required two-hour timeframe after a cognitively intact, ambulatory resident with schizoaffective disorder, bipolar type, ADHD, and an impulse disorder reported that a CNA grabbed the resident by the coat collar and pushed the resident against a wall. The allegation was communicated to the administrator by an LPN, and the administrator began but did not complete an online report to the Department of Health and Senior Services, resulting in no documented submission of the abuse allegation as required by facility policy.
Staff failed to monitor exit doors during a fire drill, resulting in a resident with psychiatric conditions eloping undetected for several hours, while two other residents also left the unit due to lack of supervision. In addition, medications were left unsecured and unattended in areas accessible to residents who wander, with staff confirming lapses in direct observation and medication security.
Staff failed to receive adequate training on behavioral health competencies and resident-specific interventions, resulting in multiple incidents where residents with mental health diagnoses engaged in verbal and physical altercations without timely or appropriate staff intervention. Staff were unsure how to access care plans or when to call behavioral crisis codes, and documentation of incidents was lacking. Residents and staff reported feeling unsafe due to the lack of effective behavioral health management.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific actions, staff, or residents are provided.
Facility staff did not notify a resident's guardian after the resident, who was moderately cognitively impaired, sustained a humeral fracture. Although the facility's policy and staff interviews confirmed the requirement to inform the responsible party of such changes, the guardian was not contacted following the injury.
Staff did not update care plans for two residents after each experienced unwitnessed falls, despite existing policies and staff knowledge that care plans should be revised following such incidents. One resident with cognitive impairment and another considered low risk for falls both had incident reports documenting falls, but no new interventions were added to their care plans. Staff interviews confirmed the expectation to update care plans, but this was not done due to other assignments.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
Facility staff did not consistently provide the number and type of nursing staff required by their own facility assessment, with staffing schedules showing shortfalls in NAs and the absence of an RCC on several days. The Staffing Coordinator was not trained to use the facility assessment for scheduling, and the administrator had not compared staffing schedules to assessment requirements. Staff interviews reflected mixed perceptions of staffing adequacy, with some noting a need for more crisis prevention education.
Staff failed to complete and document wound care treatments as ordered for two residents, with multiple missed entries on the TAR and no documentation of refusals, despite facility policy requiring timely and thorough documentation. Interviews with an LPN, the administrator, and the DON confirmed the expectation for documentation and revealed that audits were not consistently performed.
The facility staff failed to follow proper sanitation procedures, resulting in potential food contamination. Wet dishes were stacked without air drying, and unsanitary conditions were observed in the kitchens, including food debris and lime deposits. Staff interviews revealed a lack of awareness and enforcement of cleaning protocols, contributing to the deficiencies.
The facility failed to prevent the commingling of personal funds for 12 residents with the facility's operating funds, as identified in a review of records and staff interviews. The facility's policies require separate accounting for resident funds, but the Account Receivable Aging report showed residents' funds were held in the facility's operating account. Staff interviews confirmed the lack of written authorization to hold resident funds in the facility account.
The facility failed to refund personal funds to three residents within the required timeframe after discharge. Despite policies mandating refunds within 30 days of a resident's death and five days of discharge, credit balances remained unaddressed. Interviews revealed a lack of awareness and responsibility among staff, with the Business Office Manager and Corporate Account Receivable Manager acknowledging the issue but citing workload delays. The new administrator was unaware of the outstanding balances, highlighting a breakdown in communication and process adherence.
The facility failed to maintain a clean and safe environment, with observations of unclean resident rooms, broken furniture, and inadequate maintenance. Residents reported unsanitary conditions, such as feces in bathrooms and issues with wheelchairs. Insufficient housekeeping staff and poor communication among staff contributed to the deficiency.
The facility failed to provide adequate weekend activities for residents, with only Bingo and church services offered, leading to boredom and disengagement. The activities calendar was inaccurate, listing events like Father's Day in October, causing confusion. Staff shortages on weekends limited the variety of activities, and the Director of Nursing acknowledged the need for scheduled activities and accurate calendars to prevent negative impacts on residents' moods.
The facility failed to serve hot food at safe temperatures, with observations showing food items like chicken paprikash and squash served below the required 135°F. Staff used room temperature plates and ineffective plate covers, leading to cold meals. Residents reported frequent cold food, and staff lacked awareness of proper serving temperatures. The dietary manager acknowledged the issue but did not routinely check food temperatures, and the administrator was unaware of the problem.
The facility failed to conduct required pre-employment screenings for four new employees, violating their policy. The Human Resources department did not complete necessary checks, such as the Family Care Safety Registry (FCSR) and Employee Disqualification List (EDL), before hiring. Interviews revealed that the Human Resources representative and the administrator were unaware of these oversights.
Facility staff failed to document medication and treatment administration for three residents, leading to a deficiency. A resident with a diabetic foot ulcer did not have documented wound treatments and pain assessments, while another with severe cognitive impairment had missing entries for wound treatment and barrier cream application. A third resident with a feeding tube had missing documentation for syringe kit changes and tube flushing. Interviews revealed that missing signatures were not reported, and the facility's tracking system was underutilized.
A resident with a history of inserting foreign objects into their colostomy bag and stoma was repeatedly hospitalized due to the facility's failure to implement and document interventions. Despite being cognitively intact, the resident's care plan lacked strategies to prevent access to potential objects, and staff did not attempt interventions after each incident.
Facility staff failed to update care plans for two residents regarding colostomy bag use and necessary interventions. One resident's care plan lacked directions for colostomy bag use, while another resident, with a history of inserting foreign objects into their colostomy bag, had no new interventions documented despite multiple hospitalizations. The DON and MDS Coordinator acknowledged these oversights.
A resident with a surgical wound and multiple diagnoses was transferred to the hospital from a wound care appointment without notifying the guardian. Facility staff, including an LPN, DON, and Resident Care Coordinator, failed to inform the guardian, despite the facility's policy requiring notification of significant changes or transfers.
The facility staff failed to maintain an infection prevention and control program, leading to potential COVID-19 spread. Staff did not isolate COVID-19 positive residents properly, wore inappropriate PPE, and disposed of contaminated PPE incorrectly. Observations and interviews confirmed these deficiencies.
Facility staff failed to complete 72-hour neurological checks and fall follow-up documentation for two residents who had un-witnessed falls. Interviews revealed inconsistencies in understanding and executing the facility's Post Fall Protocol, with confusion about responsibility for ensuring tasks were completed. The DON admitted some staff had trouble using the PCC system, leading to gaps in required documentation.
Failure to Timely Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
Facility staff failed to timely report an allegation of sexual abuse to the State Survey Agency (DHSS) within the required two-hour timeframe. The facility’s Abuse and Neglect Policy, dated 06/12/24, requires that all allegations of abuse, including sexual assault, be reported immediately, but no later than two hours after the allegation is made, to the administrator and appropriate agencies in accordance with state and federal regulations. Resident #4, assessed as cognitively intact on a recent quarterly MDS, reported in a progress note dated 04/02/2026 that he/she had been raped in his/her sleep and requested to be sent to the hospital for a rape kit. During interviews, LPN A stated that the resident reported being raped by someone and later indicated it was a family member, and that this allegation was reported to the administrator around 5:00 A.M. LPN A said he/she was told the administrator reported the allegation to DHSS. The administrator reported receiving a call about the allegation of sexual abuse around 5:30 A.M. but acknowledged that he/she did not file a complaint with DHSS. Instead, the administrator stated he/she conducted an investigation and determined within two hours that the alleged sexual abuse did not occur, and therefore did not report the allegation to DHSS as required by policy and regulation.
Failure to Accurately Code Psychiatric Diagnoses on MDS Assessments
Penalty
Summary
Facility staff failed to complete accurate and comprehensive MDS 3.0 assessments for multiple residents with documented psychiatric diagnoses. The facility’s policy dated 11/06/23 required understanding CMS changes and accurate, timely completion of all MDS sections by responsible staff. For one resident, the diagnosis report dated 04/30/23 showed a documented bipolar disorder, and the care plan dated 3/31/26 identified bipolar disorder and schizophrenia with hallucinations and delusions; however, the resident’s quarterly MDS, dated [DATE], did not include the bipolar disorder diagnosis, even though the resident was assessed as cognitively intact. For another resident, a diagnosis report dated 06/04/25 documented PTSD, and the care plan dated 03/28/26 identified PTSD with interventions in place but without direction regarding PTSD triggers; the corresponding quarterly MDS, dated [DATE], did not include the PTSD diagnosis despite the resident being assessed as cognitively intact. A third resident had a diagnosis report dated 10/15/25 showing PTSD and a care plan dated 01/15/26 documenting a history of PTSD, yet the quarterly MDS, dated [DATE], also omitted the PTSD diagnosis while assessing the resident as cognitively intact. During an interview on 04/14/26 at 1:38 P.M., the MDS Coordinator stated that active diagnoses such as PTSD or bipolar disorder being treated should be documented on the MDS but acknowledged not knowing whether these residents had those diagnoses due to the large facility population.
Failure to Update Care Plans After New or Increased Behaviors and Suicidal Ideation
Penalty
Summary
Facility staff failed to update and individualize care plans following new or increased behaviors, including suicidal ideation and physical aggression, as required after comprehensive assessments. The facility’s policy on MDS 3.0, Care Assessment Summary and Individualized Care Plans, dated 01/06/23, lacked direction for staff on updating care plans with new interventions after new or increased behaviors. For one resident involved in a resident-to-resident altercation on 01/27/26, progress notes documented that the resident was the aggressor and reported that the holy spirit had taken over his/her body and that he/she did not need medication. However, the quarterly MDS showed the resident as cognitively intact without hallucinations or delusions, and the care plan dated 03/31/26 did not include new interventions after the altercation. Another resident, assessed as cognitively intact with depression and care planned as low risk for suicide, had no care plan guidance for staff interventions when suicidal ideation, self-harm statements, or self-harm attempts occurred. Progress notes documented that this resident reported feeling manic and wanting to hurt self, was found with a shoestring around the neck, and was later transferred to the hospital after being found with a charger cord tied tightly around the neck. Additional residents with documented aggressive or behavioral incidents, including pushing another resident to the floor and engaging in a physical altercation, and lashing out at staff and having verbal altercations, were assessed on their MDS as cognitively intact without physical or verbal behavioral symptoms. Their care plans, dated in early 2026, did not include new interventions after these incidents and lacked guidance for staff on managing behaviors. Interviews with an LPN, the administrator, and the MDS coordinator confirmed that care plans should be updated after new or increased behaviors or self-harm statements, but also revealed gaps in practice and awareness, including the MDS coordinator’s lack of knowledge about whether these behaviors were documented on PASARR for the affected residents.
Failure to Timely Report Allegation of Physical Abuse to State Agency
Penalty
Summary
Facility staff failed to report an allegation of physical abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse and neglect policy, dated 06/12/24, defined physical abuse as handling a resident with more force than is reasonable and required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. The facility census was 227. Review of the DHSS complaint/facility self-report database showed no documentation that the facility reported the allegation of physical abuse involving one resident. During an interview, the administrator stated that all allegations of abuse should be reported to DHSS within two hours and acknowledged responsibility for submitting the report. The resident involved had an annual MDS dated 01/06/26 showing he/she was cognitively intact, independent with ambulation, and had diagnoses including unspecified impulse disorder, schizoaffective disorder bipolar type, and ADHD. In an interview on 02/18/26 at 12:18 P.M., the resident reported that on the previous night a CNA held him/her by the coat collar at the neck area with a fist and slammed him/her against a wall near a doorway; the resident reported no injury and was unsure if there were witnesses. The facility’s investigation documentation, dated 02/18/26, recorded that the resident reported on 02/17/26 at approximately 7:38 P.M. that the CNA grabbed and pushed him/her, and that there were no direct witnesses and no injuries. The administrator reported being notified of the allegation at approximately 8:00 P.M. on 02/17/26 by an LPN, began an online report to DHSS, but closed the computer without confirming that the report was successfully submitted, resulting in the failure to report the abuse allegation within the required timeframe.
Failure to Supervise During Fire Drill and Inadequate Medication Security
Penalty
Summary
Facility staff failed to ensure the safety and supervision of residents in a secured unit during a fire alarm test, resulting in multiple incidents of elopement and inadequate monitoring. During the fire drill, staff did not monitor the doors on the Tiger Medical Unit, which allowed a resident with significant behavioral and psychiatric diagnoses to exit the facility undetected. Surveillance footage confirmed that the resident left the building and was not noticed missing until several hours later, despite missing dinner, smoke breaks, and scheduled medications. Hourly face checks were not completed as required, and documentation was inaccurate, with checks recorded after the resident had already eloped. Additionally, two other residents were able to leave the facility through an exit door and fence during the same fire drill, as no staff were assigned to monitor these points of egress. Staff interviews revealed a lack of clear assignments and communication regarding door monitoring during fire drills, and head counts conducted after the drill were incomplete and not systematically performed. The facility's fire drill policy did not address specific staffing assignments or door monitoring procedures for secured units during drills or emergencies. The facility also failed to properly store and secure medications for several residents. Observations found unattended medications in resident rooms and on medication carts, with residents who wander frequently present in these areas. Staff interviews confirmed that medications were sometimes left out and not always administered under direct supervision, contrary to facility policy. These lapses in medication security and supervision created opportunities for residents to access medications unsafely.
Failure to Train Staff on Behavioral Health Needs and Resident-Specific Interventions
Penalty
Summary
Facility staff failed to ensure that staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, as evidenced by multiple incidents involving residents with behavioral health diagnoses. Staff did not receive adequate training on resident-specific behaviors and interventions, and there was a lack of education on how to access and implement individualized care plans. This deficiency was observed through staff inaction during escalating resident-to-resident altercations, where staff did not intervene or utilize care planned interventions to de-escalate situations, resulting in physical altercations between residents. Additionally, staff interviews revealed uncertainty and lack of knowledge regarding when to call behavioral crisis codes and how to access or apply resident-specific interventions. Several residents with complex behavioral health needs, including diagnoses such as schizophrenia, bipolar disorder, PTSD, and impulse disorders, were involved in repeated incidents of aggression, verbal altercations, and physical assaults. In one instance, two residents engaged in a verbal and physical altercation while staff failed to intervene according to care plan interventions or call a behavioral crisis code in a timely manner. Staff members supervising the residents did not implement de-escalation techniques or follow the individualized interventions outlined in the residents' care plans. Documentation of these incidents was also lacking, with no investigation or nursing notes reflecting the altercations. Interviews with staff and residents further highlighted the deficiency, with staff expressing fear and lack of preparedness to manage residents with severe behavioral health needs. Staff reported not being trained on mental health interventions, de-escalation techniques, or how to access and apply care plan interventions. Residents reported feeling unsafe and stated that staff did not intervene until altercations became physical. The facility's failure to provide adequate training and education for staff on behavioral health needs and individualized interventions contributed directly to the incidents and ongoing unsafe environment for both residents and staff.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Failure to Notify Responsible Party After Resident's Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's responsible party after the resident experienced a significant change in condition. According to the facility's Notification of Change policy, staff are required to promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification, such as accidents resulting in injury or those with the potential to require physician intervention. Review of the resident's records showed that the resident, who was assessed as moderately cognitively impaired, sustained a humeral fracture as confirmed by x-ray. The results were reviewed with the physician, but there was no documentation or evidence that the resident's guardian was notified of the fracture. Interviews with the resident's guardian confirmed that they were not informed about the injury. Further interviews with facility staff, including an LPN, the administrator, and the DON, all indicated that staff are directed to contact the resident's family or guardian in the event of a change in condition. Despite this policy and staff understanding, the required notification to the resident's guardian did not occur following the resident's fracture.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the care plans for two residents following changes in their conditions, specifically after each experienced unwitnessed falls. For one resident, the care plan was last revised prior to a documented fall, and no new fall intervention was added after the incident. The resident was assessed as moderately cognitively impaired and at risk for falls due to confusion, incontinence, and psychoactive drug use. Despite an incident report documenting a fall, the care plan did not reflect any updated interventions addressing this event. For the second resident, the care plan was also not updated after two separate unwitnessed falls. The resident was assessed as cognitively intact and considered low risk for falls, with risk factors including psychoactive medications and extrapyramidal symptoms. Incident reports documented two falls, but the care plan did not include any new interventions following these events. Interviews with staff and administration confirmed that care plans are expected to be updated after such incidents, but this was not completed due to competing assignments and oversight.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Adequate Nursing Staff per Facility Assessment
Penalty
Summary
Facility staff failed to provide adequate nursing staff as determined by their own facility assessment, which was based on the resident population and their care needs. The facility assessment specified the required number of direct care staff for a 24-hour period, including LPNs, CMTs, CNAs, NAs, and an RCC. Review of staffing schedules over several days showed that the facility did not consistently meet these staffing requirements, with particular shortfalls in the number of NAs and the absence of an RCC on multiple days. The average daily census during this period was 235 residents, closely matching the assessment's basis. Interviews revealed that the Staffing Coordinator did not use the facility assessment to determine staffing needs and was not trained to do so. The administrator acknowledged not comparing the facility assessment to the staffing schedule and was unaware of the staffing shortfalls. The DON stated that the staffing schedule should reflect the facility assessment but believed no issues were found when recently reviewed. Staff interviews indicated a perception of adequate staffing, though some noted a need for more education in crisis prevention due to resident altercations.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not completing and documenting wound care treatments as ordered for two residents. For one resident, who was cognitively intact and had orders for multiple wound care treatments including barrier cream, Santyl ointment, and cleansing regimens, the Treatment Administration Record (TAR) showed multiple dates where treatments were not documented as completed. There was also no documentation indicating that the resident refused care on those dates. The physician orders required daily and shift-based wound care, but the records did not reflect that these were consistently provided or refused. Another resident, who was moderately cognitively impaired and had a surgical wound, had physician orders for daily application of xeroform and telfa dressings. The TAR for this resident also showed several dates where the wound care was not documented as completed, and again, there was no documentation of refusal of care. The facility's policy required wound treatments to be documented at the time of each treatment, with additional documentation if treatments were not due or if dressings were intact, as well as documentation of refusals and notifications to physicians or responsible parties. Interviews with staff, including an LPN, the administrator, and the DON, confirmed that treatments should be documented in the medical record and that refusals should be noted on the TAR. The DON acknowledged that missed treatments were identified when providing printed TARs to the surveyor and admitted that audits of the TARs had not been completed due to being too busy. The lack of documentation and failure to follow the facility's wound care policy led to the deficiency.
Sanitation Failures in Kitchen Lead to Potential Food Contamination
Penalty
Summary
The facility staff failed to adhere to proper sanitation procedures in the kitchen, leading to potential food contamination. Observations revealed that sanitized dishes were not allowed to air dry before being stacked, which can promote bacterial growth. Specifically, metal food service pans and plates were found stacked wet, with some containing food debris. Despite being aware of the issue, a dietary aide continued to use these wet dishes to serve food to residents, indicating a lapse in following the facility's policy on dish sanitation. Additionally, the facility's kitchens and kitchenette were not maintained in a clean and sanitary manner, as required by the facility's policies. Observations showed a build-up of food debris and other substances on kitchen equipment and surfaces, including steam tables, floors, and walls. The main kitchen lacked a visible cleaning schedule, and there was an accumulation of lime and calcium deposits on various surfaces. The dietary manager admitted to not having a routine schedule to check the sanitation of the kitchen and was unaware that staff were not following the cleaning schedules. Interviews with staff, including the dietary manager and the administrator, revealed a lack of awareness and enforcement of cleaning protocols. The dietary manager acknowledged responsibility for ensuring cleanliness but was unaware of the extent of the issues. The administrator also admitted to not being aware of the problems and stated that dietary staff should be trained on cleaning schedules and that routine inspections should be conducted. The facility's failure to maintain a sanitary environment and adhere to its own policies resulted in unsanitary conditions that could lead to food contamination.
Commingling of Resident Funds with Facility Operating Funds
Penalty
Summary
The facility failed to prevent the commingling of personal funds for 12 residents with the facility's operating funds, as identified in a review of the facility's records and interviews with staff. The facility's policies, including the Resident Rights policy and the Resident Trust policy, both revised in 2023, clearly state that resident funds must be kept separate from facility funds. However, the Account Receivable Aging report dated October 22, 2024, showed that residents' personal funds were held in the facility's operating account, with credit balances ranging from $184.00 to $6,651.61 for various residents. Interviews with the Business Office Manager and the Corporate Account Receivable manager revealed that the facility did not have written authorization to hold resident funds in the facility account, and both acknowledged that resident funds should not be commingled with facility funds. The Corporate Administrator, who had been overseeing the facility since June 2024, also confirmed that the facility lacked written permission to hold these credits and emphasized the importance of reviewing Account Receivable and billing weekly. The new administrator, who started the week of the survey, was informed of these responsibilities.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to provide refunds of personal funds to residents from the facility operating account within 30 days for three residents who were discharged. The facility's policy requires that upon the death of a resident, the facility must convey resident funds and a financial accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate. Additionally, within five days of a resident's discharge, the facility is required to provide an up-to-date accounting of resident funds. However, the facility's Account Receivable Aging report showed that three residents had credit balances that were not refunded within the required timeframe. Interviews with facility staff revealed a lack of awareness and responsibility for the outstanding refunds. The Business Office Manager was unaware of why the refunds had not been processed, while the Corporate Account Receivable Manager acknowledged the issue but cited being behind on work as the reason for the delay. The new administrator, who started at the facility recently, was also unaware of the outstanding balances and stated that the business office and administrator are responsible for reviewing accounts receivable and billing. The Corporate Administrator, who had been at the facility since June, was also unaware of the outstanding credit balances until informed during the survey.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous observations of unclean and poorly maintained resident rooms and common areas. Observations included black scuff marks, sticky floors, broken furniture, and debris in various resident rooms and common areas. Additionally, there were reports of feces in a resident's bathroom that had not been cleaned, leading to an unpleasant and unsanitary environment. Interviews with residents and staff revealed dissatisfaction with the cleanliness and maintenance of the facility, with some residents expressing that their rooms were not cleaned after previous occupants moved out. The facility's housekeeping and maintenance policies were not consistently followed, as evidenced by the lack of deep cleaning and maintenance in resident rooms and common areas. Staff interviews indicated that there were often insufficient housekeeping staff on weekends, leading to inadequate cleaning and maintenance. The housekeeping supervisor admitted to not conducting regular checks for cleanliness, and the maintenance director was unaware of certain maintenance issues until they were pointed out by surveyors. Residents reported issues with their wheelchairs, such as missing armrests and built-up debris, which were not addressed despite being reported to staff. The facility's failure to maintain clean and functional assistive devices further contributed to the deficiency. The lack of coordination and communication among staff, as well as insufficient staffing levels, were significant factors in the facility's inability to provide a safe and comfortable environment for its residents.
Inadequate Weekend Activities and Inaccurate Calendar
Penalty
Summary
The facility staff failed to provide an ongoing activity program designed to meet the residents' interests, mental, and psychosocial well-being on the weekends for six residents out of 35 sampled residents. The activities calendar posted on Tiger Lane was inaccurate, listing events such as Father's Day in October, which confused residents. Interviews with residents revealed dissatisfaction with the limited activities offered on weekends, primarily consisting of Bingo and church services, leading to boredom and a lack of engagement. Interviews with staff, including Certified Medication Technicians, Certified Nurse Aides, and the Activities Director, highlighted the challenges faced in providing adequate activities on weekends. The facility had only one activity staff member available on weekends, which limited the variety and frequency of activities. Staff expressed that more activities could prevent residents from becoming bored and potentially getting into conflicts with each other. The Activities Director acknowledged the inaccuracies in the posted calendar and the difficulty in arranging activities without sufficient staff support. The Director of Nursing and Corporate Administrator recognized the need for scheduled weekend activities and the importance of an accurate activity calendar. They noted that incorrect events, such as Father's Day in October, could negatively impact residents' moods, especially those with a history of trauma. The lack of diverse and engaging activities on weekends was a significant deficiency, affecting the residents' quality of life and psychosocial well-being.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility staff failed to ensure that hot food items were served at a safe and appetizing temperature, as observed during meal service on the 400 and 500 halls. The facility's Dietary Food Preparation policy requires hot foods to be served at temperatures greater than 135 degrees Fahrenheit, preferably between 160 to 170 degrees Fahrenheit. However, observations revealed that the internal temperatures of hot food items, such as chicken paprikash with pasta and squash, were significantly below the required temperature, measuring at 109.4 degrees Fahrenheit and 95.7 degrees Fahrenheit, respectively. The dietary manager acknowledged the temperature discrepancy but continued to serve the food without reheating it to the proper temperature. Further observations showed that the dietary aide prepared meal trays using room temperature plates and covered them with metal plate covers that had open holes, which did not retain heat effectively. The trays were then placed on an open wheeled bakery rack cart for delivery. Interviews with staff members revealed a lack of awareness regarding the correct serving temperatures for hot foods, with one staff member incorrectly believing that 72 degrees Fahrenheit was acceptable. Residents reported that their food was often served cold, indicating a recurring issue with maintaining appropriate food temperatures. The dietary manager admitted that the metal plate covers with holes were used due to storage limitations and acknowledged that this contributed to the problem of cold food. Additionally, the dietary manager did not routinely check the temperatures of foods served on carts in the unit, and there was no communication with the administrator regarding the need for different plate covers. The administrator was unaware of the issues with food temperatures and stated that the dietary manager was responsible for monitoring food temperatures, highlighting a lack of oversight and communication within the facility's management.
Failure to Conduct Pre-Employment Screenings
Penalty
Summary
The facility staff failed to conduct necessary pre-employment screenings for four out of ten new employees, which is a violation of their policy. The policy requires the Human Resources department to perform pre-employment checks to ensure applicants have not committed disqualifying crimes, are not excluded from federal or state healthcare programs, and are eligible to work in the United States. Specifically, the checks should include a Criminal Background Check (CBC) through the Missouri Highway Patrol or a Family Care Safety Registry (FCSR) check, and an Employee Disqualification List (EDL) check. However, the records showed that these checks were either requested or completed after the employees were hired, which is against the facility's policy. The personnel records revealed that Dietary Aide S, [NAME] Y, Housekeeper N, and Activity Aide K were hired before the completion of the required checks. For instance, Dietary Aide S was hired on 09/25/23, but the FCSR check was requested on 09/27/23. Similarly, [NAME] Y was hired on 12/04/23, with checks completed on 12/06/23. Housekeeper N and Activity Aide K also had their checks completed after their respective hire dates. During interviews, the Human Resources representative acknowledged the oversight, stating that the expectation is for all checks to be completed before hiring. The administrator also expressed that they were unaware of the incomplete checks prior to the hiring dates.
Documentation Lapses in Medication and Treatment Administration
Penalty
Summary
The facility staff failed to document the administration of medications and treatments for three residents, leading to a deficiency in meeting professional standards of quality. Resident #115, who had intact cognition and a diabetic foot ulcer, did not have documented wound treatments and pain assessments on multiple occasions in September and October 2024. The resident reported that the wound clinic recommended daily bandage changes, but facility staff changed it every three to four days, indicating a discrepancy in care. Resident #132, with severe cognitive impairment and a venous ulcer, also experienced lapses in documentation. The Treatment Administration Record (TAR) lacked entries for wound treatment and the application of barrier cream after incontinence on several days in October 2024. This lack of documentation suggests that the necessary treatments may not have been administered as prescribed. Resident #219, who had moderate cognitive impairment and a feeding tube, had missing documentation for changing the syringe kit, cleansing the feeding tube site, and flushing the feeding tube with water. These omissions occurred throughout August, September, and October 2024. Interviews with the Resident Care Coordinator (RCC) and the Director of Nursing (DON) revealed that missing signatures on the TARs and MARs were not reported, and the facility's dashboard for tracking missed medications was not effectively utilized.
Failure to Supervise Resident with Risky Behavior
Penalty
Summary
The facility staff failed to provide adequate supervision for a resident with a history of inserting foreign objects into their colostomy bag and stoma, leading to multiple hospitalizations. The resident, who was assessed as cognitively intact, had documented incidents of inserting objects such as a paperclip, fork, spoon, and other foreign items into their colostomy bag and stoma. Despite these repeated incidents, the resident's care plan did not include specific interventions to address this behavior, and staff did not implement or document any corrective actions following each occurrence. Interviews with facility staff, including the Charge Nurse and Director of Nursing (DON), revealed that there were no interventions attempted after each incident, and the care plan lacked strategies to prevent the resident from accessing silverware or other potential objects. The DON acknowledged that if interventions had been attempted, it might have prevented future incidents. The facility's failure to implement and document appropriate interventions and supervision measures contributed to the resident's repeated hospitalizations due to the insertion of foreign objects.
Failure to Update Care Plans for Colostomy Bag Use and Interventions
Penalty
Summary
The facility staff failed to document and update care plans for two residents regarding the use of colostomy bags and necessary interventions. Resident #2, who was cognitively intact and used an ostomy bag, had a care plan that did not include directions for the use of the colostomy bag, despite having a physician's order for it. The Director of Nursing (DON) and the MDS Coordinator acknowledged the oversight and admitted that the care plan should have been updated to include this information. Resident #1, also cognitively intact and using a colostomy bag, had a history of inserting foreign objects into the colostomy bag and stoma, leading to multiple hospitalizations. Despite these incidents, the care plan had not been updated with new interventions since February 2024. Interviews with the Charge Nurse, DON, and the administrator revealed that no new interventions were attempted or documented after each incident, although they agreed that such actions should have been taken and recorded in the care plan.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party when the resident was transferred to the hospital from a wound care appointment. The facility's policy requires staff to inform the resident, consult the resident's physician, and notify the resident's representative of significant changes in the resident's condition or when a transfer occurs. However, in this case, the staff did not document any notification to the resident's guardian about the transfer. The resident, who was cognitively intact, had a surgical wound on the right foot and several diagnoses, including metabolic encephalopathy and diabetes with circulatory complications. The resident's care plan included a left below-the-knee amputation and a right transverse foot amputation. Interviews with facility staff, including an LPN, the DON, and the Resident Care Coordinator, revealed that there was an expectation to notify the guardian, but it was not done. The guardian was unaware of the transfer until contacted by the hospital for permission to treat the resident.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment, leading to the potential spread of COVID-19 and other infections. Staff did not follow acceptable infection control practices, such as separating residents who tested positive for COVID-19 from those who tested negative or had only been exposed. This failure increased the risk of contracting COVID-19 for several residents due to prolonged exposure. Additionally, staff did not consistently wear the appropriate Personal Protective Equipment (PPE) when interacting with COVID-19 positive residents, nor did they remove and dispose of contaminated PPE appropriately. Observations revealed multiple instances where COVID-19 positive residents were not isolated properly. For example, the door to a room with two COVID-19 positive residents was left open, and a Certified Nurse Aide (CNA) was observed sitting close to one of the residents with only an N95 respirator on, lacking gloves, face shield, or gown. Other observations showed COVID-19 positive residents without masks, doors to their rooms open, and no PPE stations outside the rooms. Staff, including maintenance workers and the assistant administrator, entered rooms of COVID-19 positive residents without full PPE and continued to wear the same N95 masks after exiting the contaminated areas. Further observations indicated improper PPE removal and disposal practices. Staff were seen removing PPE in hallways and placing contaminated PPE in regular trash bags instead of bio-hazard bags. Interviews with staff, including CNAs, housekeepers, and the Director of Nursing (DON), confirmed that there was confusion and inconsistency regarding the proper use and disposal of PPE. The DON acknowledged that staff should wear full PPE when entering COVID-19 positive rooms and should remove PPE inside the room, placing it in red bio-hazard bags, not regular trash bags.
Failure to Complete Neurological Checks and Documentation After Un-witnessed Falls
Penalty
Summary
Facility staff failed to complete 72-hour neurological checks and fall follow-up documentation for two residents who had un-witnessed falls. The facility's Post Fall Protocol requires neurological assessments and detailed documentation following an un-witnessed fall, but these were not completed for the residents in question. Resident #1, who was cognitively intact and independent for mobility, had un-witnessed falls on two separate occasions, but the required neurological checks and documentation were not found in the medical record. Similarly, Resident #2, who was cognitively intact and used a wheelchair for mobility, also experienced an un-witnessed fall, and the necessary follow-up was not documented in the medical record. Interviews with various staff members, including LPNs, CMTs, RCCs, and the DON, revealed inconsistencies in the understanding and execution of the facility's Post Fall Protocol. Staff members acknowledged that neurological checks should be initiated and documented in Point Click Care (PCC) for 72 hours following an un-witnessed fall. However, there was confusion about who was responsible for ensuring these tasks were completed, with some staff indicating that the DON or RCCs were ultimately responsible. Despite this, the required documentation was not completed for the residents involved. The DON admitted that some staff had trouble using the PCC system and occasionally resorted to paper documentation, which was then scanned into PCC. However, this process was not consistently followed, leading to gaps in the required neurological checks and follow-up documentation. The failure to adhere to the facility's Post Fall Protocol resulted in incomplete assessments and documentation for the residents who experienced un-witnessed falls.
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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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