Garden View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in O Fallon, Missouri.
- Location
- 700 Garden Path, O Fallon, Missouri 63366
- CMS Provider Number
- 265321
- Inspections on file
- 19
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Garden View Care Center during CMS and state inspections, most recent first.
A resident with significant cognitive impairment and a history of hypersexuality engaged in repeated non-consensual sexual contact with several other cognitively impaired residents, including touching, kissing, and groping. Despite multiple incidents witnessed or reported by staff, the facility did not implement effective interventions or consistently assess capacity to consent, and key leadership was not informed of the ongoing abuse.
Staff failed to report multiple incidents of sexual abuse involving cognitively impaired residents to the state agency and resident representatives, despite facility policy requiring prompt notification. The incidents, which included inappropriate touching and kissing by a resident with a history of such behaviors, were documented in progress notes but not communicated to authorities or families. Interviews revealed confusion among staff about reporting responsibilities and a lack of awareness among leadership regarding the events.
A resident with moderate cognitive impairment reported being stalked and hit by an unidentified individual. Despite consistent accounts of the incident, the facility's administrator did not conduct a formal investigation or report the allegations to the state agency, citing conflicting stories. The facility's policy requires prompt reporting and investigation of abuse allegations, but the administrator and DON did not adhere to this policy, resulting in a deficiency.
A resident with moderate cognitive impairment alleged being hit by a CNA, but the facility failed to conduct a timely investigation or suspend the CNA, contrary to its policy. The resident reported feeling unsafe, but the Administrator dismissed the claims as delusional without notifying the state agency. The facility's inaction led to a deficiency finding.
A resident with a history of trauma and mental health disorders exhibited increased paranoia and reported being hit, but the facility failed to implement a care plan addressing these issues. Staff were unaware of the resident's psychiatric history, and care plans lacked interventions for trauma and behavioral changes. The facility did not provide trauma-informed care or educate staff on PTSD, leading to inadequate support for the resident's mental health needs.
The facility failed to maintain cleanliness and sanitation in the kitchen and nourishment centers, with issues such as soiled surfaces, improper use of hair and beard restraints, and uncovered food items during transport. Ice machines were in poor condition, with buildups of debris and broken doors, exposing ice to contamination. These deficiencies highlight significant lapses in food safety and sanitation standards.
The facility failed to ensure proper hand hygiene during resident care, with staff not washing hands or changing gloves appropriately. Additionally, the facility did not complete required TB tests for new employees and failed to monitor cold water temperatures to prevent Legionella growth. These deficiencies indicate lapses in infection control and employee health screening protocols.
A facility failed to provide adequate incontinence and oral care for two residents. One resident, with severe cognitive impairment, was repeatedly observed with strong urine and fecal odors, indicating a lack of timely incontinence care. Additionally, oral care was often neglected due to time constraints. Another resident, requiring substantial assistance with oral hygiene, reported not receiving help, and observations confirmed the absence of oral care supplies in the room.
The facility failed to ensure resident safety by not following transfer protocols for a resident with severe cognitive impairment, requiring two-person assistance. A CNA assisted the resident alone without a gait belt, leading to an unsafe transfer. Additionally, the facility did not properly document or address a fall incident involving another resident, failing to follow fall protocols and implement new interventions. Staff interviews revealed a lack of communication and documentation regarding the fall.
The facility failed to properly manage oxygen tubing for two residents with COPD, as their care plans lacked directives for changing or dating the tubing. Observations showed undated tubing, and staff interviews revealed inconsistencies in responsibility for changing and documenting the tubing. The facility lacked a policy for this task.
The facility failed to remove expired medications and COVID-19 test kits, with some items remaining for over 100 days past expiration. Medications for a discharged resident were also found 182 days after discharge, and medications without orders were stored for a current resident. The DON admitted to not checking the storage room recently, and the LPN was unaware of the medications' presence.
The facility's pest control program was ineffective, resulting in a roach infestation in the kitchen and dishwashing areas. Observations showed insects crawling near kitchen equipment, and interviews revealed delayed responses to pest sightings due to a billing issue with the pest control company. The facility's policy requires an ongoing pest control program, but recent treatments only addressed the exterior, not the interior.
A facility failed to assess and document the use of bed rails for a resident with a history of falls and mobility issues. The facility did not conduct a risk assessment for entrapment, document alternatives, or obtain informed consent before using bed rails. Despite the resident's care plan indicating the use of side rails, there was no physician's order or necessary documentation. The DON acknowledged the lack of required assessments and documentation, yet the decision to keep the bed rail was made without proper protocol.
A facility failed to perform regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency in identifying potential entrapment hazards. A resident with a history of falls and mobility issues used a half bed rail without documented assessment or consent. The Maintenance Director was unaware of his responsibility to measure bed rails for entrapment zones, and no safety checks were conducted, as required by facility policy.
The facility failed to provide written transfer notices to residents and/or their representatives when six residents were transferred to the hospital. Despite the facility's policy requiring written notice before transfers, there was no documentation of such notices in the medical records of the affected residents. This deficiency was confirmed by the Administrator, who noted that nurses were not providing the necessary notices during transfers.
The facility failed to provide written notice of the bed hold policy to residents or their representatives within 24 hours of hospital transfer, affecting four residents. Despite the policy requiring written communication, staff only discussed it via phone without documentation. The Administrator confirmed that nurses were not providing the policy as required.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from sexual abuse by another resident who exhibited a pattern of inappropriate sexual behaviors. One resident with significant cognitive impairment and a history of hypersexuality was repeatedly observed or reported to have engaged in non-consensual sexual contact with several other residents, all of whom had documented cognitive deficits or dementia and lacked the capacity to consent to sexual activity. Incidents included the resident putting hands down another resident's pants and touching the perineal area, rubbing another resident's breasts, kissing a resident on the mouth, and groping a resident's breast. These events occurred in various locations within the facility, including resident rooms and common areas, and were witnessed or reported by staff on multiple occasions. Despite these repeated incidents, there was no evidence that the facility implemented new or effective interventions to protect the affected residents or prevent further abuse after each event. Documentation showed that staff often redirected the resident or removed them from the situation, but there was no indication of comprehensive assessment, increased supervision, or other protective measures being put in place following the incidents. Additionally, the facility did not consistently notify the families or representatives of the affected residents about the incidents, nor did they document assessments of the residents' capacity to consent to sexual contact, as required by facility policy. Interviews with staff and administration revealed a lack of awareness and communication regarding the ongoing behaviors and incidents. Key leadership, including the DON and Administrator, were not informed of several incidents until much later, and some staff did not recognize the behaviors as abuse, attributing them instead to memory care behaviors. The facility's policies required assessment of capacity to consent and interventions to prevent abuse, but these were not followed. The affected residents all had diagnoses of dementia or other cognitive impairments, and their representatives confirmed that the residents would not have wanted or been able to consent to such contact.
Failure to Report Sexual Abuse Allegations Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report multiple witnessed and documented incidents of sexual abuse involving three residents who lacked the capacity to consent to sexual activity. Staff observed a resident with a history of sexually inappropriate behaviors, including rubbing another resident's breasts, kissing a resident on the mouth, and groping a resident's breast. Despite these incidents being documented in progress notes and discussed among staff, there was no evidence that the events were reported to the state agency or to the residents' representatives as required by facility policy and federal regulations. The residents involved had significant cognitive impairments, including diagnoses of Alzheimer's disease, dementia, and major depressive disorder with psychotic symptoms, and were documented as having impaired judgment and decision-making abilities. The facility's own policies required prompt reporting of all allegations of abuse to appropriate authorities and to the residents' representatives, as well as evaluation of capacity to consent for any resident involved in sexual activity. However, there was no documentation of such evaluations or notifications in the residents' records, and interviews with representatives confirmed they were not informed of the incidents. Interviews with staff revealed a lack of clarity and follow-through regarding reporting responsibilities. Some staff believed the behaviors were not abuse due to the perpetrator's cognitive status, while others assumed incidents had already been reported or did not recognize the need to report. Leadership, including the DON and Administrator, were unaware of the incidents until much later and acknowledged that the events should have been reported according to policy. The failure to report these incidents constituted a violation of both facility policy and regulatory requirements.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report allegations of physical abuse involving a resident to the state agency. The resident, who was admitted to the facility with moderate cognitive impairment, reported being stalked and hit by an unidentified individual. Despite the resident's consistent account of the incident, the facility's administrator did not conduct a formal investigation or report the allegations to the state agency, citing conflicting stories and the resident's denial of being hit when questioned. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be promptly reported to the appropriate authorities and thoroughly investigated. However, the administrator and the Director of Nursing did not adhere to this policy. The administrator received reports of the resident's allegations from various staff members, including the Social Services Director and Activity Assistant, but dismissed them as delusional without further investigation. Interviews with staff revealed that the resident had expressed fear and distress over the alleged abuse, even leaving a note on their door warning against entry. Despite these clear signs of distress and the facility's policy requirements, the administrator failed to take the necessary steps to ensure the resident's safety and report the incident, resulting in a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation following an allegation of physical abuse made by a resident. The resident, who has moderate cognitive impairment, reported being hit by a young person fitting the description of a Certified Nurse Aide (CNA) working at the facility. Despite the resident's allegations, the facility did not suspend the CNA or conduct a formal investigation, allowing the CNA to continue working, which did not align with the facility's policy for handling abuse allegations. The resident expressed feeling unsafe and reported the incident to various staff members, including an Activity Assistant and the Social Services Director. The Social Services Director reported the incident to the Administrator, but the Administrator dismissed the allegations as delusional without conducting a formal investigation or notifying the state agency. The Director of Nursing (DON) also failed to investigate the CNA as a potential abuser, assuming the resident's claims were delusional. The facility's policy requires immediate suspension of any employee accused of abuse and a thorough investigation, which was not followed in this case. The Administrator acknowledged receiving reports of the allegations but did not take appropriate action, resulting in a failure to protect the resident and ensure their safety. The lack of a formal investigation and failure to report the incident to the state agency contributed to the deficiency identified by the surveyors.
Failure to Address Trauma and Mental Health Needs
Penalty
Summary
The facility failed to provide appropriate care and interventions for a resident with a significant history of trauma and mental health disorders, including major depressive disorder, generalized anxiety disorder, and panic disorder. The resident, who had experienced severe trauma in the past, began exhibiting increased paranoia and reported being hit by an unidentified person. Despite these symptoms, the facility did not have a care plan in place to address the resident's history of trauma or the current behavioral changes. Interviews with facility staff revealed a lack of awareness and understanding of the resident's psychiatric history and the potential impact of past trauma on current behavior. The Licensed Practical Nurse/MDS coordinator and the Social Services Director admitted to not having read the psychiatric notes, which documented the resident's traumatic experiences and ongoing mental health issues. The resident's care plans did not include interventions to address the trauma or the recent behavioral changes, such as paranoia and feelings of being unsafe. The facility's failure to incorporate trauma-informed care and appropriate interventions into the resident's care plan was further highlighted by the lack of staff education on trauma and PTSD. The Director of Nursing and the Administrator acknowledged the need for staff to be aware of the resident's psychiatric history and to implement interventions to manage the resident's paranoia and trauma-related symptoms. The physician also emphasized the importance of recognizing the role of past trauma in the resident's current mental health status and the need for targeted interventions.
Sanitation and Hygiene Deficiencies in Kitchen and Nourishment Centers
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen and nourishment centers, as observed during a survey. Numerous issues were identified, including opened containers of salad dressing and mayonnaise without expiration or use-by dates, soiled lids on bulk flour and sugar bins, and uncovered pans of gelatin in the refrigerator. The kitchen surfaces, including the floor under the freezer and refrigerator, were soiled with debris, and there was a presence of mold-like debris on fan covers in the refrigerator. Additionally, the facility did not ensure proper use of hair and beard restraints by dietary staff, leading to potential contamination of food items. The ice machines in the kitchen and nourishment centers were found to be in poor condition, with heavy buildups of slimy yellow and crusty white debris, and a lack of proper air gaps in the drainage system. The door to the ice machine in the C Wing nourishment center was broken and could not close, leaving the ice exposed to contamination. Despite maintenance attempts, the issue persisted, and staff reported the problem had been ongoing for months. The facility's policy required regular cleaning and maintenance of these machines, but these procedures were not adequately followed. Furthermore, the facility failed to cover food and drink items when transporting meal trays to residents' rooms. Observations showed that while plates were covered, desserts and drinks were left uncovered during transport, increasing the risk of contamination. The dietary manager acknowledged these lapses, noting that all food items should be covered, and staff should adhere to hygiene practices, including wearing appropriate hair and beard restraints. These deficiencies highlight significant lapses in the facility's adherence to food safety and sanitation standards.
Inadequate Infection Control and TB Screening in LTC Facility
Penalty
Summary
The facility failed to ensure proper hand hygiene practices among staff during personal care for four residents. Observations revealed that staff members did not wash their hands or change gloves appropriately between tasks, particularly when moving from soiled to clean tasks. For instance, a CNA was observed cleaning a resident's perineal area and then touching clean supplies without changing gloves or washing hands. This was a common issue across multiple staff members, indicating a systemic failure to adhere to the facility's hand hygiene policy. Additionally, the facility did not complete required Tuberculin Skin Tests (TST) and annual evaluations for tuberculosis for three new employees. The employee files lacked documentation of the necessary two-step TST or any annual TB evaluations. Interviews with the DON/Infection Preventionist revealed a lack of awareness and follow-through on these requirements, leading to non-compliance with the facility's TB screening policy. The facility also failed to monitor cold water temperatures as part of their water management program, which is crucial for preventing the growth of waterborne pathogens like Legionella. The maintenance director admitted to not measuring cold water temperatures and was not fully aware of the risks associated with Legionella growth. This oversight indicates a gap in the facility's infection prevention and control program, as the water management policy was not being fully implemented.
Deficiencies in Incontinence and Oral Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services for incontinence and oral care for two residents. Resident #1, who had severe cognitive impairment and was dependent on staff for personal hygiene, was observed multiple times with strong urine and fecal odors, indicating a lack of timely incontinence care. Despite being incontinent of bowel and bladder, staff did not consistently check or change the resident every two hours as required, leading to the resident being transported to the dining room with soiled clothing. Additionally, Resident #1 did not receive adequate oral care. Observations showed debris around the resident's mouth, and staff interviews revealed that oral care was often neglected due to time constraints. The facility's policy lacked specific documentation on when staff should assist with oral care, contributing to the oversight. Resident #29, who required substantial assistance with oral hygiene, also did not receive proper oral care. The resident reported not receiving assistance, and observations confirmed the absence of oral care supplies in the room. The resident's electronic health record lacked documentation of oral hygiene being provided, highlighting a systemic issue in the facility's care practices.
Failure to Ensure Resident Safety and Proper Fall Protocols
Penalty
Summary
The facility failed to ensure resident safety by not adhering to the care plan and transfer protocols for a resident with severe cognitive impairment and high fall risk. The resident required extensive assistance from two staff members for transfers, as indicated in the care plan. However, during an observation, a CNA assisted the resident alone without using a gait belt, which was against the facility's policy. The CNA acknowledged the need for a second person due to the resident's agitation but proceeded alone due to a lack of available staff. This resulted in an unsafe transfer process, where the CNA used their leg to support the resident, which was deemed inappropriate by the DON. Another deficiency was identified in the facility's handling of a fall incident involving a resident with moderately impaired cognition and a history of falls. The resident fell out of bed and was taken to the hospital, but the facility failed to document the incident comprehensively in the progress notes. Essential details such as the time, location, and activity prior to the fall, as well as injury description and treatment, were missing. The facility's fall protocol was not followed, as there was no documentation of a root cause analysis or implementation of new interventions to prevent future falls. Interviews with staff revealed a lack of communication and documentation regarding the fall incident. The LPN on duty during the fall did not document the incident in the progress notes and failed to implement or communicate any new interventions. The DON confirmed the absence of a fall report and documentation in the electronic health record. Despite the resident's fall, no new interventions were added, as the DON believed they were unnecessary due to the resident's lack of previous falls.
Failure to Properly Manage Oxygen Tubing for Residents
Penalty
Summary
The facility failed to properly store, change, and date oxygen tubing for two residents, leading to a deficiency in respiratory care. Resident #4, who was cognitively intact and used oxygen for chronic obstructive pulmonary disease (COPD), had no directive in their care plan to change or date the oxygen tubing. Observations over several days showed the resident using oxygen tubing without any date or initials, and the resident could not recall the last time the tubing was changed. The facility's records, including the Treatment Administration Record (TAR) and Physician Order Sheet (POS), did not specify when the oxygen tubing should be changed. Similarly, Resident #39, diagnosed with COPD and using continuous oxygen, also had no directive for changing or dating the oxygen tubing in their care plan. Observations showed the resident using undated and uninitialed oxygen tubing over multiple days. Interviews with staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed inconsistencies in understanding and executing the responsibility for changing and documenting the oxygen tubing. The facility lacked a policy for changing and dating oxygen tubing, as confirmed by the administrator.
Expired Medications and Testing Supplies Not Removed
Penalty
Summary
The facility failed to ensure that expired testing supplies and medications not in use were destroyed or returned as per facility policy. Specifically, medications for a discharged resident remained in the facility for 182 days after discharge, and expired COVID-19 test kits were not removed or destroyed, remaining in the facility for up to 132 days past expiration. These items were found during an observation of the medication storage room. Additionally, medications labeled for a current resident were found in the storage room without corresponding physician orders since the resident's admission. These included various medications such as atorvastatin, cyclobenzaprine, and sertraline, among others. The LPN interviewed was unaware of why these medications were in the cabinet, how long they had been there, or who placed them there. It was noted that sometimes families brought medications from home, which the facility could not use, and these were supposed to be taken back by the family. The Director of Nursing (DON) acknowledged responsibility for checking the medication storage room but admitted the last check was two weeks prior. The DON was unaware of the presence of expired COVID-19 tests and medications for the residents in question. The DON stated that expired medications should be placed in a destruction container, and anyone noticing outdated COVID-19 tests could dispose of them. However, these procedures were not followed, leading to the deficiency.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in the kitchen and dishwashing areas. Observations revealed light brown insects crawling along the walls and floors near heated carts, trash cans, and kitchen equipment. The facility's pest control policy, revised in May 2024, mandates an ongoing program to keep the building free of insects and rodents, with services provided by a pest control vendor. However, the pest control company's service summary report from December 2024 only indicated treatment of the facility's exterior for rodents and ants, with no recent interior treatment noted. Interviews with the Dietary Supervisor and Administrator revealed a lack of timely response to pest sightings. The Dietary Supervisor acknowledged a report of a roach in the service hallway on January 11, 2025, but did not act on it as it was not in the kitchen. The pest control company was contacted on January 13, 2025, but a billing issue delayed their response. The Administrator was unaware of the current insect issues in the kitchen until informed by the Dietary Supervisor. The pest control technician confirmed an ongoing issue with roaches, although the volume had decreased, and stated that healthcare facilities are prioritized for pest control services.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for a resident, leading to a deficiency. The facility did not assess the resident for risk of entrapment prior to the placement of bed rails, nor did they document any alternatives attempted before deciding to use bed rails. Additionally, the facility did not complete entrapment zone measurements or obtain written consent from the resident or their guardian before the use of the bed rails. The resident involved had a history of falls, unsteadiness on feet, and required substantial assistance for mobility. The resident's care plan indicated the use of half side rails to maximize independence with turning and repositioning in bed. However, there was no physician's order for the bed rails, and the resident's medical record lacked a bed rail assessment, entrapment assessment, or informed consent documentation. During an interview, the Director of Nursing acknowledged the absence of necessary orders, assessments, consents, or entrapment zone measurements for the resident's bed rail. Despite considering the removal of all bed rails, the facility and the resident decided it was in the resident's best interest to keep the bed rail. This decision was made without the proper documentation and assessments required by the facility's policies.
Failure to Conduct Bed Rail Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which are crucial for identifying potential entrapment hazards. This deficiency was observed in the case of a resident who used a half bed rail for assistance with mobility. The facility's policies required routine inspections and assessments to ensure the safe use of bed rails, but these were not completed. The Maintenance Director, who was responsible for these inspections, was unaware of his duties regarding measuring bed rails for entrapment zones and had not conducted any such assessments since his employment began three months prior. The resident involved had a history of falls and required substantial assistance with mobility due to a recent shoulder fracture. Despite the resident's reliance on the bed rail for safety and mobility, there was no documented assessment, physician order, or informed consent for the use of the bed rail. Interviews with the Maintenance Director and the Director of Nursing revealed a lack of awareness and execution of the necessary safety checks and documentation, contributing to the oversight in ensuring the resident's safety.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notices of transfer to residents and/or their representatives when six residents were transferred to the hospital. This deficiency was identified during a review of 14 sampled residents, where it was found that the facility did not adhere to its own Transfer or Discharge Notice policy. The policy requires that written notice be given as soon as practicable before a transfer or discharge, including details such as the reason for transfer, effective date, location, and appeal rights. However, in these cases, there was no evidence that such notices were provided. For instance, Resident #29 was transferred to the hospital twice, on two separate occasions, due to medical complaints, but there was no documentation of a written notice being provided to the resident's representative. Similarly, Resident #16 was transferred to the hospital with a pulmonary embolism, and Resident #11 was transferred following a fall and subsequent shoulder fracture, yet neither had written notices documented in their medical records. These omissions were consistent across other residents, including Resident #35, who was transferred due to swelling and respiratory issues, and Resident #251, who was transferred due to symptoms related to congestive heart failure. The facility's failure to provide written notices was confirmed during an interview with the Administrator, who acknowledged that the nurses were not sending transfer notices with the residents or providing them to the representatives upon transfer. This oversight indicates a systemic issue in the facility's process for handling transfers and discharges, as evidenced by the lack of documentation in the medical records of the affected residents.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to residents or their representatives within 24 hours of transfer to a hospital, affecting four residents out of a sample of 14. The facility's policy requires that when a resident is transferred to a hospital, the bed hold policy must be communicated in writing to the resident or their representative. However, in the cases of Residents #11, #16, #35, and #251, there was no evidence that this policy was provided as required. Resident #16 was transferred to the hospital due to elevated fever, decreased oxygen saturation, and increased respiratory effort, and was diagnosed with a pulmonary embolism. Resident #11 was transferred after a fall resulted in a right shoulder fracture. Resident #35 was sent to the hospital with symptoms including periorbital edema, confusion, and shortness of breath. Resident #251, who was their own responsible party, was transferred due to breathing difficulties and suspected weight gain. In all these cases, the facility did not provide the required bed hold policy documentation. Interviews with facility staff revealed that the Admission Director contacted residents or their representatives by phone to discuss the bed hold policy but did not document these discussions. The Administrator acknowledged that the nurses were supposed to provide the bed hold policy upon transfer, but this was not being done. This lack of documentation and communication led to the deficiency identified by the surveyors.
Latest citations in Missouri
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
