Gideon Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gideon, Missouri.
- Location
- 300 Lunbeck, Gideon, Missouri 63848
- CMS Provider Number
- 265409
- Inspections on file
- 12
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Gideon Care Center during CMS and state inspections, most recent first.
Failure to accommodate resident needs and preferences: A resident with COPD had an oxygen concentrator that repeatedly beeped and was not replaced despite the resident reporting poor sleep, frustration, and anxiety. In the dining room, a resident with dementia and weakness and another resident said the table was too high and made it hard to reach food, while a resident with dementia, DM, CKD, and COPD was observed with the call light on the floor out of reach despite needing staff help.
A resident was discharged from skilled Medicare services without documentation that a SNF ABN was issued to the resident or representative at least 2 calendar days before services ended. The facility policy required written notice when Medicare payment denial or a change in coverage was likely, but the record contained no SNF ABN. The Administrator said she assumed the notice was not provided and signed because she could not find one, and stated it must have been missed by Social Services Designees.
Failure to Post Required Daily Nurse Staffing Information: The facility did not post the required daily nurse staffing information in a prominent location accessible to residents and visitors for 3 of 4 observed days. The Staff Posting Sheet across from the nurse's station was missing the required licensed and unlicensed nursing staff counts and actual hours worked. An LPN said each shift was responsible for completing the sheet, and the DON and Administrator stated the sheet should include the staff worked and total hours worked.
The facility failed to accurately document, dispose of, and reconcile controlled substances for two residents. An unlocked narcotic lock box was found in a medication refrigerator with lorazepam bottles whose remaining amounts did not match the narcotic count log, and a morphine bottle in the medication cart also did not match the recorded count. The DON said staff should lock the box after counting and report discrepancies immediately, while an LPN said the count was off but had not yet informed the DON.
Failure to follow EBP and wound care infection control was observed for a resident with diabetes and two left leg wounds. Staff inconsistently used PPE, one LPN entered without a gown, hand hygiene was not performed after glove changes, and ointment was applied directly with a gloved finger instead of a no-touch method. The dressing was also not dated and initialed, and no EBP signage was posted outside the room.
A facility failed to consistently document a resident's code status, leading to conflicting information in the medical records. The resident's face sheet indicated CPR status, while other documents suggested a DNR status. Interviews with staff and the resident highlighted the inconsistency, with the resident expressing a preference for DNR. The Director of Nursing and Administrator acknowledged the need for consistent documentation.
The facility failed to maintain a safe, clean, and homelike environment, with observations of peeled paint, exposed sheetrock, non-functioning light fixtures, and buildup of dirt and spider webs. Despite the facility's policy, these issues were not documented in the maintenance log, and interviews revealed a lack of communication and follow-up on environmental concerns, potentially affecting all 60 residents.
The facility failed to implement comprehensive care plans with specific interventions for five residents. One resident's care plan did not address pressure ulcers, while three residents admitted to hospice care lacked hospice-related interventions. Another resident's care plan inaccurately required smoking supervision despite an assessment indicating it was unnecessary. The Administrator acknowledged the expectation for care plans to reflect residents' care needs.
The facility failed to obtain a physician order for hospice services for a resident and did not adhere to prescribed insulin administration times for multiple residents. Interviews confirmed that insulin should be administered shortly before meals, and a physician order is expected for hospice services. These deficiencies highlight lapses in following physician orders and facility policies.
The facility failed to provide ordered restorative nursing services to residents with limited ROM, resulting in missed sessions for three residents. Despite orders for restorative care three times a week, residents experienced numerous missed opportunities due to staff being reassigned to other duties. Interviews with staff revealed an expectation for services to be provided, but documentation was lacking.
The facility failed to label and date food items and maintain temperature logs, increasing the risk of food-borne illness for all residents. Observations showed unlabeled and undated food in various storage areas and incomplete temperature logs. Interviews confirmed lapses in adherence to food safety policies, with staff acknowledging missing records and unresolved maintenance issues.
The facility failed to implement proper infection control practices during medication administration through a PICC line and did not adhere to enhanced barrier precautions and hand hygiene during incontinent and catheter care for residents. Staff did not follow facility policies, leading to potential risks of infection spread among residents.
The facility did not document the provision of education on the benefits and side effects of influenza and pneumococcal vaccines for four residents. Despite the facility's policy requiring such documentation, records showed no evidence of education being provided before vaccine administration or refusal. Interviews with the ADON and DON confirmed this oversight.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not replacing an oxygen concentrator for a resident with chronic respiratory conditions, by not adjusting dining table height for residents during meals, and by not keeping a call light within reach for a resident who needed assistance. The report identified these issues through observation, interview, and record review for residents in and outside the sample. Resident #18 was admitted with pneumonia, chronic respiratory failure, hypoxia, anxiety disorder, and COPD. The resident had orders for oxygen at 4 L per minute via nasal cannula and for cleaning and maintenance of the oxygen concentrator and tubing. During observations, the resident’s oxygen concentrator made a loud continuous beeping sound multiple times while in bed, in the activities room, and at the bedside. The resident repeatedly turned the concentrator off and back on to stop the beeping. In interview, the resident said the concentrator had kept him/her up at night for over a week, was beeping about every 30 minutes, and was very frustrating and anxiety-provoking. Staff interviews showed that a beeping concentrator should be reported to the charge nurse and replaced if needed, and the DON stated the facility should always have a spare concentrator. The maintenance repair log did not address the resident’s concentrator concern. Resident #31 had diagnoses including dementia, heart failure, chronic kidney failure, and weakness. During observations in the dining room, the resident sat in a wheelchair at the table with his/her arms and shoulders below table level and had difficulty reaching food to eat. Another resident, Resident #42, said the table was a little too high and sometimes made it difficult to reach food served. Staff also stated the tables looked too tall for some residents and appeared to have adjustable legs. In addition, Resident #54, who had diagnoses including type II DM, chronic kidney failure, dementia, and COPD and required staff assistance with ADLs, was observed in bed with the call light lying on the floor out of reach. The resident said the call light was used to request staff help and to go to the restroom. Multiple staff members and the DON stated call lights should always be within reach of residents.
Failure to Issue SNF ABN Before End of Skilled Medicare Services
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) in writing at least two calendar days before a resident was discharged from skilled Medicare services. The deficiency affected one resident out of three sampled residents, and the resident remained in the facility after discharge from skilled services on 01/24/26. The record review showed no documentation that the resident or the resident's representative received a SNF ABN. The facility's policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated September 2024, stated that Medicare beneficiaries are to be informed in advance and in writing when Medicare payment denial or a change in coverage is likely, and that a SNF ABN CMS Form 10055 is to be issued before care that Medicare usually covers may not be paid for under the current circumstance. During interview, the Administrator stated she assumed a SNF ABN was not provided and signed because she could not find one, and said it must have been missed by the Social Services Designees.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for three of four observed days. The census was 62. Review of the facility policy titled, "Posting Direct Care Daily Staffing Numbers," dated August 2022, showed the facility was to post, within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care, along with the total number of staff and actual hours worked. Observations of the Staff Posting Sheet, located on a window across from the nurse's station, showed the required daily nurse staffing information was not posted for 03/16/26, 03/17/26, and 03/18/26. During interviews, an LPN said each shift was responsible for filling out the staffing sheet with the hours worked and the staff worked. The DON said she expected each nurse on each shift to completely fill out the staffing sheet as soon as they arrived, including the staff hours worked and the total hours for each shift. The Administrator also said the nurses should be filling out the staffing sheet completely with the actual staff worked and the total hours worked.
Medication Reconciliation and Controlled Substance Documentation Failure
Penalty
Summary
The facility failed to implement procedures to ensure medications were accurately documented, disposed of, and reconciled for two residents. During observation of the 300 Hall medication room refrigerator, an unlocked narcotic lock box was found inside the refrigerator with two opened bottles of lorazepam for two residents. The observed amounts remaining in the bottles did not match the narcotic count log: one resident’s lorazepam bottle had 16 ml remaining while the log showed 20 ml remaining, and the other resident’s bottle had 18 ml remaining while the log showed 22.5 ml remaining. The facility policy required controlled substances to be separately locked and for the oncoming and off-going nurses to count together and document discrepancies. During interview, the DON said nurses should lock the narcotic lock box before returning it to the refrigerator after counting medications and stated she was unaware the narcotic count was off. She also said that if a resident refused a dose of a narcotic, a waste form should be completed, but staff did not fill them out as they should and she had no follow-up process for refusals or wasting medications. An LPN stated he counted the narcotics with an RN at shift change, knew the count was off for the two residents, but had not yet informed the DON, and said he normally locked the narcotic lock box back but must have forgotten. In a separate observation, a bottle of morphine for one resident in the medication cart showed 20 ml remaining, while the narcotic count log showed 26 ml remaining.
Failure to Follow EBP and Wound Care Infection Control
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) and infection control practices during wound care for one resident with left leg wounds. The resident had diagnoses including type 2 diabetes mellitus, acquired absence of the right leg above the knee, hypertension, anxiety, and depression. The resident’s physician orders directed staff to cleanse and dress two left leg wounds three times daily, including application of gentamicin ointment and dressing changes. During observation of wound care, staff placed EBP supplies outside the resident’s door, but no EBP signage was posted. On multiple observations, an LPN and an RN entered the room with varying PPE use, including one instance where an LPN did not put on a gown before entering. Staff removed soiled dressings, cleaned the wounds, and changed gloves at times, but hand hygiene was not performed after glove changes as observed. Staff also applied gentamicin ointment directly with a gloved finger rather than using a no-touch technique, and did not perform hand hygiene or change gloves between wound applications. The wound care observations also showed that the dressing was applied without dating and initialing it. Interviews with staff and leadership indicated they understood EBP was required for residents with wounds and that gown and gloves should be used for wound care, with hand hygiene after glove changes. The DON and Administrator stated they expected staff to use a cotton-tipped applicator or tongue depressor when applying ointments or creams to wounds.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to obtain a physician's order for a resident's code status and to consistently document the code status across the resident's medical records. This deficiency was identified for one resident out of a sample of 15, in a facility with a census of 60. The resident's medical record showed conflicting information: a CPR code status on the face sheet, a red dot indicating DNR on the hard chart, and a red sheet labeled DNR. Additionally, an Outside the Hospital Do Not Resuscitate Order was signed by both the resident and the attending physician. However, the Physician Order Sheet contained an order for CPR status, creating inconsistency in the documentation. Interviews with the resident and staff revealed further discrepancies. The resident expressed a desire for a DNR status and mentioned signing a document to that effect. A registered nurse indicated that they would check the electronic medical record for the resident's code status, while the Director of Nursing and the Administrator both acknowledged that the code status should be consistent across all records. This inconsistency in documentation and failure to obtain a proper physician's order for the resident's code status led to the identified deficiency.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. These included areas of peeled paint and exposed sheetrock in various rooms, non-functioning ceiling light fixtures in the women's bath area, and a buildup of dirt, debris, and spider webs in several locations, including the main entrance and exit doors of different halls. The facility's policy on maintaining a homelike environment was not adhered to, as these conditions were not documented in the maintenance log, and no corrective actions were noted. Interviews with housekeeping staff and the Maintenance Supervisor (MS) revealed a lack of communication and follow-up on environmental concerns. Housekeepers reported writing down issues in the maintenance log and verbally informing the MS, but no recent concerns were noted. The MS and the Administrator expected staff to document and report issues, yet the maintenance log showed no recorded concerns during the specified period. This lack of documentation and follow-up contributed to the ongoing environmental deficiencies, potentially affecting all 60 residents in the facility.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans with specific interventions for five residents, as required by their policy. Resident #36's care plan did not address interventions for pressure ulcers, despite having diagnoses of muscle weakness, COPD, and pressure ulcers at stages 2 and 3. Residents #38, #41, and #48, who were admitted to hospice care, had care plans that did not include interventions related to their hospice admission. These residents had various diagnoses, including Alzheimer's disease, major depressive disorder, hypertension, hypothyroidism, diabetes mellitus, hyperlipidemia, generalized anxiety, psychosis, cerebral infarction, vascular dementia, atrial fibrillation, hemiplegia, and dysphagia. Resident #56's care plan inaccurately required supervision while smoking, despite an IDT assessment determining the resident was safe to smoke without supervision. The care plan had not been updated to reflect this assessment. During an interview, the Administrator acknowledged that she would expect the care plan to reflect the resident's care needs, including hospice admission. The facility's failure to update and implement care plans with specific interventions for these residents indicates a deficiency in meeting the residents' individual needs.
Deficiencies in Physician Orders and Insulin Administration
Penalty
Summary
The facility failed to obtain a physician order for hospice services for a resident admitted to hospice care. The resident, diagnosed with Parkinson's Disease, hypertension, and osteoarthritis, was admitted to hospice on March 10, 2024. However, the physician order for hospice services was not present in the resident's December 2024 Physician Order Sheet, and the hospice admission order was not signed and dated by a physician, only by a hospice RN. Additionally, the facility did not adhere to prescribed insulin administration times for several residents. One resident with diagnoses of systolic congestive heart failure and diabetes mellitus had multiple instances where Novolin R insulin was administered significantly later than the ordered times. Another resident with dementia, dysphagia, and diabetes mellitus also experienced delays in receiving Fiasp insulin according to the sliding scale order. A third resident with hypertensive heart, chronic kidney disease, and diabetes mellitus had similar issues with delayed administration of Fiasp insulin. Interviews with the Director of Nursing and the Administrator confirmed that insulin should be administered shortly before meals, ideally 10-15 minutes prior. The Director of Nursing also acknowledged the expectation for a physician order for hospice services for residents receiving such care. These deficiencies highlight lapses in following physician orders and facility policies regarding timely medication administration and proper documentation for hospice care.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility staff failed to provide appropriate restorative nursing services to residents with limited range of motion (ROM), as evidenced by missed opportunities for scheduled restorative care. Three residents, identified as Residents #23, #30, and #35, did not receive the ordered restorative services intended to maintain or improve their ROM. The facility's policy mandates that residents receive individualized restorative nursing care to promote safety and independence, yet this was not consistently implemented. Resident #23, diagnosed with generalized muscle weakness and gait impairment, was ordered to receive restorative nursing services three times a week. However, documentation revealed numerous missed sessions over a three-month period, with 10 missed opportunities in October, six in November, and four in December. Similarly, Resident #30, who is dependent for all activities of daily living and has impairments in both upper and lower extremities, also experienced missed restorative sessions, with nine missed in October, five in November, and four in December. Resident #35, with diagnoses including dementia and stroke, also had missed restorative sessions, with six missed in October, three in November, and four in December. Interviews with facility staff, including a Restorative Nurse Aide (RNA) and the Director of Nursing (DON), revealed that the RNA was often reassigned to other duties, such as assisting with transports and showers, which contributed to the missed restorative sessions. The DON and the facility Administrator both expressed an expectation that residents should receive the restorative services as ordered, but there was a lack of documentation to confirm whether services were provided when the RNA was reassigned. This deficiency highlights a failure in the facility's ability to consistently deliver necessary restorative care to residents as per their care plans.
Food Safety and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to its food safety policies, resulting in several deficiencies related to food labeling, dating, and temperature monitoring. Observations revealed multiple instances of food items in the stand-up refrigerator, walk-in refrigerator, and walk-in freezer that were not labeled or dated, including sausage biscuits, a container of soup, a bag of ham, and opened sausage patties. Additionally, the chest freezer temperature logs were incomplete, with missing entries for several days. These practices increased the risk of cross-contamination and food-borne illness for all 60 residents in the facility. Interviews with the Dietary Manager and staff confirmed that the facility's policy required food to be labeled and dated upon opening, and temperatures to be checked and recorded daily. However, the Dietary Manager acknowledged awareness of missing temperature records and the ongoing issue of a leaking pipe under the triple sink, which had been unresolved since March 2024. Dietary staff also confirmed their responsibility for ensuring food was properly labeled and dated, and for maintaining temperature logs, but admitted to lapses in these duties. The Administrator expressed expectations aligned with the facility's policy but was unaware of the leaking pipe issue.
Infection Control Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during the administration of medications through a peripherally inserted central catheter (PICC) for one resident. The staff did not follow the facility's policy for disinfecting the needleless access device before connecting or disconnecting the syringe, which is crucial to prevent infections. Additionally, the biohazard waste was not stored properly, with bags left on the floor and trash protruding from barrels, which could pose a risk of contamination. The facility also did not adhere to enhanced barrier precautions (EBP) and proper hand hygiene during incontinent care and catheter care for two residents. Staff members failed to perform hand hygiene before and after glove changes and did not use gloves and gowns as required by EBP guidelines. This lack of adherence to infection control protocols during high-contact care activities could increase the risk of spreading infections among residents. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of compliance with the facility's infection control policies. Staff members admitted to not performing hand hygiene between glove changes and not being familiar with EBP requirements. The facility's failure to ensure proper infection control practices and adherence to policies had the potential to affect all residents in the facility.
Failure to Document Vaccine Education
Penalty
Summary
The facility failed to document the provision of education regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines for four residents out of five sampled. The facility's policy, revised in October 2019, mandates that residents or their legal representatives be informed about the benefits and potential side effects of vaccinations, with this education documented in the resident's medical record. However, the records for Residents #7, #21, #30, and #56 showed no documentation of such education being provided, despite the administration or refusal of the influenza vaccine. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the lack of documentation. The ADON acknowledged that the facility did not document the provision of vaccine education in the medical records. The DON stated that the facility should be educating residents or their representatives about the risks and benefits of vaccines before administration, indicating a lapse in following the established policy.
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.
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