Golden Years Center For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisonville, Missouri.
- Location
- 2001 Jefferson Parkway, Harrisonville, Missouri 64701
- CMS Provider Number
- 265349
- Inspections on file
- 23
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 11 (3 serious)
Citation history
Health deficiencies cited at Golden Years Center For Rehab And Healthcare during CMS and state inspections, most recent first.
The facility used its van with an expired vehicle registration to transport residents to physician appointments several times a week, despite having a policy requiring safe, compliant transportation and the availability of other transportation services. Emails between facility administration and the parent company showed ongoing awareness that the van’s registration had expired and that the title was needed to renew it. Observation confirmed the expired plate sticker, and review of transportation logs showed repeated use of the van for resident appointments while some residents were transported by outside companies. In interviews, the van driver, an LPN, and the Administrator all acknowledged that the van’s license had expired the previous year, that administration knew about it, and that the van continued to be used for resident transport during this period.
A resident with dementia and anxiety, who was his/her own responsible party, was moved to a different room, including a locked memory care unit, without documented written notice or a signed agreement for the room change. The care plan indicated the room move had been discussed and agreed to, but the resident later reported not agreeing, becoming very upset and tearful, and feeling trapped in the locked unit. Staff, including CNAs and an agency LPN, stated that residents were supposed to receive written notice and that all parties should agree before a room change, but they were unsure if this occurred for this resident. EMR review showed no guardian or DPOA and no uploaded agreement related to the move, and the DON confirmed the resident had not been notified in writing and acknowledged unawareness of the regulatory requirement.
Two residents were affected when staff failed to follow and document physician orders for diagnostic testing. One resident with urinary retention, neuromuscular bladder dysfunction, and an indwelling catheter had multiple UAs ordered and marked as completed in the system, but the EMR contained no notes of urine collection attempts, refusals, or any UA results, despite care plan notes that the resident sometimes refused catheter care. Another resident with C. diff enterocolitis and morbid obesity fell while rising from a commode; after an X-ray could not be obtained, a CT of the back and right side was ordered, but the resident reported not being informed of the CT or a scheduled date, and the hospital scheduler stated the CT order was not received until days later and was initially invalid, preventing scheduling. Facility leadership and staff acknowledged that all MD orders should be followed and that attempts, refusals, and fax confirmations should be documented, but such documentation was absent in these cases.
The facility did not provide required behavioral health services, failed to implement PASRR processes, and did not ensure administration of psychotropic medications for several residents with serious mental illness. Staff lacked training in de-escalation and behavioral health, and did not document or address escalating aggressive behaviors, resulting in an unsafe environment for both residents and staff.
Two residents did not receive necessary medical care as ordered, including missed doses of anti-rejection and psychotropic medications and lack of required wound care. Staff failed to communicate with physicians and the transplant team, did not document or reconcile medications, and lacked training in caring for post-transplant and psychiatric residents. These failures led to severe health complications, including infection, hospitalization, and behavioral crises.
A resident who was recently admitted after a kidney transplant did not receive prescribed antirejection and immunosuppressive medications due to failures in medication reconciliation, ordering, and administration. Staff were unaware of the process for handling medications sent from the hospital, did not ensure timely pharmacy delivery, and failed to notify the physician or take action when medications were unavailable. The resident was readmitted to the hospital with sepsis and undetectable antirejection medication levels, confirming the missed doses.
Two residents were subjected to physical and verbal abuse by another resident with a history of mental health disorders, leading to one resident leaving the facility due to fear and humiliation, and another nonverbal, cognitively impaired resident suffering pain, visible injury, and emotional trauma after being struck and pushed in a wheelchair. Staff and witnesses confirmed the incidents, and the facility did not prevent or adequately intervene in the aggressive behaviors, despite policies prohibiting abuse.
Staff at the facility did not receive adequate training or education in behavioral health management, resulting in an inability to safely care for residents with complex psychiatric and behavioral needs. Multiple staff members reported feeling unprepared and fearful, and there was a lack of incident reporting, care plan updates, and behavioral interventions for residents exhibiting aggressive, violent, or self-harming behaviors. This led to repeated incidents of harm to both staff and residents, as well as frequent involvement of law enforcement.
A resident's dignity was violated when an LPN called the resident "dumb" during a care interaction, leading to the resident becoming visibly upset, expressing emotional distress, and requesting not to have the LPN as a caregiver. Multiple staff witnessed the incident and confirmed the resident's account, and the facility's policy on resident rights was not upheld.
The facility did not maintain a full-time DON or ensure RN coverage for at least eight hours per day, seven days a week. During a period between the termination of the previous DON and the hiring of a new DON, staff—including an LPN acting as ADON—confirmed that RN coverage was inconsistent and agency RNs were only used occasionally. Staff often relied on phone consultations with former DONs for guidance, rather than having an on-site RN or DON as required.
A resident with morbid obesity and complex care needs was transferred to a hospital without proper discharge documentation, reassessment, or a 30-day notice. The facility refused to readmit the resident after hospitalization, citing inability to meet care needs, and did not provide required notifications regarding appeal rights or bed-hold policies.
Two residents did not receive all prescribed medications, and required blood pressure monitoring was not completed for one resident with orders for as-needed antihypotensive medication. Missed doses were not documented on the MAR, and there was no evidence of physician notification or progress note entries explaining the omissions, despite facility policy and staff interviews indicating these steps were required.
Two residents received medications and water flushes via G-tube without verification of tube placement or measurement of external tube length, as an LPN did not check placement before administration. Facility leadership and staff were unaware of current best practices for G-tube placement verification, and no policy for G-tube medication administration was provided.
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, with issues including debris buildup, improper food storage, unlabeled containers, and uncleanable cutting boards and spatulas. The Dietary Manager and Dietary Cook acknowledged these deficiencies during interviews.
The facility failed to provide required in-service training for dementia care and abuse prevention for three CNAs, with inconsistent training offerings and incomplete documentation of attendance, as confirmed by staff interviews and training records review.
The facility failed to ensure residents who allowed the facility to manage their funds received interest payments and did not have signed authorization forms for three residents. Bank statements showed no interest payments, and the Corporate Director of Fiscal Services was unaware of any changes. The Business Office Manager could not locate authorization forms for these residents, all of whom had legal guardians.
The facility failed to maintain water temperatures at handwashing faucets in several resident rooms at or above 105°F, with observed temperatures ranging from 84.5°F to 103.1°F. Additionally, the facility did not maintain clean sprinkler heads in various areas and failed to repair two stand-up lifts with cracked bases. Staff acknowledged these issues but did not take immediate corrective actions.
The facility failed to notify the ombudsman of resident discharges/transfers for three residents. The Social Services Designee had been emailing the list of discharges to an incorrect email address, resulting in the ombudsman not being informed as required.
The facility failed to ensure a resident's care plan included necessary PT, OT, and ST, despite orders and initiation of these therapies. The omission was due to incomplete documentation following a change in the facility's computer systems.
The facility failed to update care plans for five residents with changes in their conditions and needs, and did not invite a resident to their care plan meeting. Issues included unupdated hospice care, missing IV antibiotics, and overdue care plan goals. Interviews revealed that care plans were not consistently updated due to a change in computer systems.
The facility's Activity Director did not meet the required qualifications, lacking formal training and certification, leading to a deficiency identified by surveyors.
The facility failed to provide ordered Restorative Aide (RA) services to three residents, leading to a decline in their Range of Motion (ROM). Staff interviews and documentation revealed that RAs were frequently pulled to work as CNAs, resulting in inconsistent delivery of RA services.
The facility failed to ensure proper maintenance and sanitation of respiratory equipment for several residents with COPD and CHF. Observations revealed undated and improperly stored oxygen tubing and nebulizer masks, and interviews with staff highlighted inconsistencies in responsibilities and practices.
The facility failed to ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, as required. The facility's staffing schedule and interviews revealed that there was no RN coverage on certain days, particularly weekends, despite the facility's policy and CMS reports indicating the need for adequate RN staffing.
The facility failed to ensure that the Medication Regimen Review (MRR) was responded to for four residents. The Consultant Pharmacist made recommendations regarding medication adjustments and assessments, but there were no documented responses from the physicians. This lack of response was observed for residents with complex medical histories, including mental health conditions and chronic pain, who were on multiple psychotropic and pain medications.
The facility failed to monitor medication refrigerator temperatures and remove expired medications in the Rehabilitation Unit. Observations showed a blank temperature log and expired medications, including Acetaminophen and glycerin suppositories. Staff interviews revealed a lack of knowledge about responsibilities for these tasks, and the DON confirmed that night shift staff were responsible for temperature logs, while the DON or ADON should audit for expired medications.
The facility failed to ensure that four residents with broken or missing teeth were seen by a dentist. Despite residents informing staff about their dental needs, no appointments were scheduled, and care plans did not reflect any dental issues. Staff were generally unaware of the residents' dental needs.
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Residents reported receiving cold food almost every day, and the Dietary Manager did not take effective measures to address the issue. Observations showed that hot foods were not maintained at the required temperature of 120 F, and cold foods were not kept at or below 41 F. Staff confirmed that food temperatures were not monitored at the point of service.
The facility's administration failed to implement a plan of correction by the designated date, resulting in continued deficient practices affecting residents' well-being. The facility did not complete 12 out of 16 required audits due to the abrupt departure of the previous administrator, leading to a lack of continuity and oversight.
The facility failed to identify and correct quality deficiencies through its QAPI plan, leading to continued deficient practices affecting residents' well-being. The facility did not complete 12 out of 16 required audits, and the Corporate Administrator revealed that many completed audits went missing when the previous administrator abruptly left the position.
The facility failed to maintain an infection prevention and control program by not providing TB testing for five sampled residents. The facility's policy required TB screening for all residents, but records showed no evidence of TB testing or screening for the sampled residents. Interviews revealed that the responsibility for administering TSTs was assigned to nurses, but the tests were not conducted or documented properly.
The facility failed to offer and document pneumococcal and influenza vaccinations for five residents, despite policies requiring these actions. Interviews revealed a lack of follow-through and oversight by the admitting nurses and administration.
The facility failed to provide and document COVID-19 vaccinations for three residents, compromising the infection prevention and control program. Interviews revealed inconsistencies in the vaccination process and lack of proper documentation, leading to this deficiency.
The facility failed to update a resident's code status from full code to DNR despite having an advance directive indicating DNR. The admitting nurse did not ensure the resident's wishes were reflected on the chart, and there was no clear process for auditing code statuses.
The facility failed to provide two residents with a written summary of a baseline care plan within 48 hours of admission. Critical information was missing, and residents were unaware of their care plans. Interviews revealed that baseline care plans were not being printed, signed, or provided to residents or their families.
The facility failed to accurately document the administration of pain medication for one resident and ensure another resident had taken their prescribed medications. Discrepancies in the records for Oxycodone administration and improper handling of medications left at a resident's bedside were observed, indicating non-compliance with the facility's policies.
The facility failed to ensure that bathing/showers were completed at least once weekly and according to the residents' preferences for two residents. One resident with colostomy status and hypertension missed multiple weeks of showers, while another with hypertension and glaucoma did not receive showers for specific weeks. Staff interviews revealed inconsistencies in the shower schedule and documentation, and the facility's shower policy lacked specific guidelines on frequency.
The facility failed to ensure physician-ordered weekly weights were completed for a resident with significant weight loss and tube feeding. Staff interviews revealed that Restorative Aides responsible for weighing residents were often reassigned to other duties, resulting in missed weight measurements.
The facility failed to maintain proper communication and documentation with the dialysis center for a resident with end-stage kidney disease, as evidenced by missing dialysis sheets and lack of documentation. The facility's policy did not address communication protocols, leading to this deficiency.
The facility failed to ensure psychotropic medications were administered for specific conditions and that PRN orders were limited to 14 days without review. One resident did not have documented physician rationale for Lorazepam, and another did not receive a gradual dose reduction for Duloxetine and Lurasidone despite pharmacist recommendations. Interviews revealed inconsistencies in following medication management policies.
The facility failed to ensure the lids of the dumpsters were closed after staff placed trash in them. This was observed on multiple occasions, and the Dietary Manager stated that all departments were expected to keep the dumpsters closed to prevent raccoons from accessing the trash.
The facility failed to maintain the siding on the outside of the former dementia unit and behind the kitchen, creating openings that pests could get into. Observations revealed damaged siding with visible insulation and gaps, which the Maintenance Director confirmed existed before his tenure.
A facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in treatment and documentation. One resident developed an infected pressure ulcer on the coccyx, with no weekly skin assessments or proper documentation in the EMR. Another resident had unstageable pressure ulcers, but the facility did not perform weekly assessments or document the wounds. The wound nurse mistakenly believed hospice nurses were responsible for documentation, resulting in a lack of proper tracking and assessment.
Use of Facility Van with Expired Registration for Resident Transportation
Penalty
Summary
The facility failed to ensure its transportation van was properly licensed in accordance with State law while continuing to use it to transport residents to medical appointments. Review of the facility’s transportation policy showed it committed to providing safe, non-emergency transportation with a well-maintained van and appropriate liability and insurance coverage. Emails between the facility’s administrative team and the parent company documented ongoing awareness that the van’s registration had expired and that the title was needed to complete registration, with multiple communications about tracking down or obtaining duplicate titles and identifying facilities with expired registrations. Observation of the van showed a license plate sticker indicating expiration in 2025, and review of the transportation log showed multiple instances over several days in which residents were transported to physician appointments using the facility van, while some residents were transported by outside transportation companies. During interviews, the van driver stated that the van was used several times a week to transport residents, confirmed the license had expired the previous year, and reported being told the facility would pay any ticket if the van was pulled over, adding that other transportation services were available and that they would not drive their personal vehicle with expired tags. An LPN similarly reported that the van’s license had expired the previous year, that administration was aware, that the van was used a couple of times a week for resident appointments, and that administration was responsible for keeping the license current and probably should not have been driving it with expired tags. The Administrator acknowledged that the van’s license had expired the previous year after the new company purchased the facility, that the parent company was having difficulty obtaining the title from the previous owner and had referred the matter to its legal department, and that the van continued to be used several times a week for resident transportation despite the expired license, even though other transportation companies were available.
Failure to Provide Written Notice and Obtain Agreement for Resident Room Change
Penalty
Summary
The facility failed to honor a resident’s right to be informed and to exercise self-determination regarding a room change. A resident with unspecified dementia of unspecified severity without behavioral disturbance and an anxiety diagnosis was admitted as his/her own responsible party, with no guardian or DPOA documented. The resident’s care plan noted dementia and documented that on 1/6/26 a room move was discussed and the resident agreed, and that on 1/7/26 staff were assisting with the move when the resident became upset and stated a desire to leave the facility. A quarterly MDS dated 1/8/26 showed the resident had severely impaired cognition and no wandering behavior. During a later interview, the resident reported not agreeing to the room move, becoming very upset and tearful, not understanding why he/she had been moved to a locked unit, and feeling trapped there, and was unable to state whether written notice of the room change had been received. Record review of the EMR showed the resident had no guardian or DPOA, was his/her own responsible party, and there was no signed agreement uploaded related to the room move. Multiple staff interviews (two CNAs and an agency LPN) confirmed that all residents were supposed to receive written notice of room moves and that all parties needed to agree before a room change, but they were unsure whether this resident had received written notice; the agency LPN reported the resident was upset and refused to move while being escorted down the hall. The DON confirmed the resident had not been notified in writing about the room move, was unsure why written notification had not been provided, and stated unawareness of the regulation, while acknowledging the resident should have been notified in writing. The facility’s own Resident Rights policy stated that information about resident rights and responsibilities would be given orally and in writing, but there was no documentation that written notice of the room change had been provided to this resident.
Failure to Follow and Document Physician Orders for UA and CT Imaging
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were followed and appropriately documented for two residents. One resident with urinary retention, neuromuscular bladder dysfunction, severely impaired cognition, and an indwelling catheter had physician orders for urinalyses in December 2025, with the electronic order status showing both tests as completed. However, review of the electronic medical record revealed no nursing notes related to collection of the ordered urine specimens and no laboratory results for any urinalysis in December. The resident’s care plan included monitoring and reporting signs and symptoms of UTI and noted that the resident had a fixation with the genital area and sometimes refused catheter care, but there was still no documentation that staff attempted to obtain the ordered UAs, that the resident refused, or that collection was otherwise unsuccessful. For the second resident, who had diagnoses including enterocolitis due to C. difficile and morbid obesity, an unwitnessed fall occurred while the resident was attempting to stand from a commode. An X-ray was ordered but could not be obtained due to the resident’s abdominal size, and the physician then ordered a CT scan of the back and right side. The facility’s order summary showed the CT scan order, and staff interviews indicated that the order was to be faxed to a local hospital. The resident later reported being unaware that a CT scan had been ordered and not being given a scheduled date for the procedure. A hospital scheduling manager reported not seeing a CT order for the resident until several days after the order date and stated that the CT had not been scheduled because the facility sent an invalid order that required correction before scheduling. The administrator, CNAs, LPNs, and the DON all stated that physician orders were expected to be followed as written and that failed attempts to collect UAs or send out imaging orders should be documented in the EMR, MAR, or TAR, including confirmation of fax receipt when applicable. The DON confirmed there was no documentation that the UAs for the first resident could not be collected and no documentation confirming that the CT order for the second resident had been sent or received before the date identified by the hospital scheduler.
Failure to Provide Behavioral Health Services and Medication Management
Penalty
Summary
The facility failed to provide appropriate treatment and behavioral health services to multiple residents with known mental health diagnoses and behavioral health histories. For three sampled residents, the facility did not implement required Preadmission Screening and Resident Review (PASRR) processes, failed to create or update care plans with necessary interventions for behaviors, and did not ensure the administration of prescribed psychotropic medications. One resident with a complex psychiatric history, including paranoid schizophrenia, anxiety disorder, and substance dependence, was admitted without the facility having the PASRR on file, and staff did not administer the resident's psychotropic medications as ordered. This resident exhibited escalating aggressive behaviors, including physical aggression toward staff and other residents, verbal outbursts, and attempts to elope, with no documented incident reports, care plan updates, or behavioral interventions during these episodes. Staff interviews revealed a lack of training and competency in managing behavioral health needs. Multiple staff members, including LPNs, CNAs, and housekeepers, reported not receiving education or in-service training on de-escalation techniques, behavioral health, or abuse and neglect prevention. Staff expressed feeling unprepared and unsafe when caring for residents with aggressive behaviors, and several reported that their concerns and requests for guidance from facility leadership were ignored. Documentation showed that staff were instructed not to document certain behavioral incidents, and there was a lack of behavior monitoring, incident reporting, and psychiatric follow-up for residents exhibiting significant behavioral symptoms. Other residents and staff reported feeling unsafe due to the aggressive behaviors of affected residents, with some residents stating they were traumatized or unable to sleep due to fear. Law enforcement was called multiple times to manage out-of-control behaviors, and police officers expressed concern about the facility's ability to manage residents with behavioral health needs. The facility's failure to provide required behavioral health services, medication management, and staff training resulted in an environment where both residents and staff were at risk, and appropriate care and oversight were not provided for residents with serious mental illness and behavioral challenges.
Failure to Administer Critical Medications and Provide Wound Care
Penalty
Summary
The facility failed to meet the medical needs of two residents, resulting in significant deficiencies. One resident was admitted with end stage renal disease and a recent kidney transplant, requiring strict adherence to a complex medication regimen including multiple immunosuppressants and specific wound care for a surgical site. Upon admission, the facility did not document a review of the medication list with the facility physician, failed to ensure the availability and administration of critical anti-rejection medications, and did not provide the ordered wound care for two and a half days. Staff documented that medications were not given because they were waiting for pharmacy delivery, despite the medications being sent with the resident from the hospital. There was also a lack of documentation and communication regarding the resident's transplant status, infection control needs, and high-risk medication protocols in the care plan. The facility's staff, including the DON, LPNs, and CMTs, demonstrated a lack of knowledge and training regarding the care of post-transplant residents and the importance of timely administration of high-risk medications. Interviews revealed that staff were unaware of the significance of missed doses, did not know who was responsible for ensuring medication availability, and failed to notify the resident's physician or transplant team about missed medications and wound care. The wound care nurse and other staff expressed discomfort and lack of experience with the required wound care, leading to further delays. Attempts by the resident's transplant team to communicate with facility staff were unsuccessful, and the transplant team was not informed of the missed medications or wound care lapses. As a result of these failures, the resident was admitted to the hospital with undetectable levels of anti-rejection medication, sepsis, and a necrotic surgical wound, requiring IV antibiotics and multiple surgeries. In a separate incident, another resident did not have their psychotropic medications reconciled or administered, leading to behavioral outbursts and eventual hospitalization for psychiatric care. The facility's policies for medication administration, wound care, and special needs management were not followed, and there was a breakdown in communication and documentation at multiple levels of staff responsibility.
Failure to Administer Critical Antirejection Medications Post-Transplant
Penalty
Summary
A significant medication error occurred when a resident, recently admitted following a kidney transplant, did not receive critical antirejection and immunosuppressive medications as ordered. The resident was discharged from the hospital with a supply of essential medications, including Tacrolimus, Myfortic, Prednisone, Valganciclovir, and Bactrim, and had a therapeutic level of antirejection medication at the time of discharge. Upon admission, the facility failed to document the presence of these medications, and the care plan did not address the need for post-transplant antirejection therapy. Facility staff did not administer the ordered medications on multiple occasions, citing that they were waiting for the pharmacy to deliver them. Medication Administration Records (MAR) and medication card observations confirmed that several doses were missed, and staff documented the absence of medication as the reason. Interviews with staff, including the DON, CMT, and LPNs, revealed a lack of knowledge regarding the process for reconciling and ordering medications upon admission, as well as uncertainty about who was responsible for ensuring timely medication availability. Staff also reported that the DON was informed about the missing medications, but no action was taken to resolve the issue or notify the attending physician. The resident was subsequently readmitted to the hospital with sepsis and a near-undetectable level of antirejection medication, as confirmed by laboratory results and the transplant team. Hospital and transplant staff confirmed that the resident had received all necessary medications prior to discharge and that missing even a single dose could result in serious harm. The facility's failure to ensure the resident received prescribed antirejection medications led to a significant medication error and placed the resident at risk for organ rejection and severe illness.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical and Emotional Harm
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by another resident, resulting in both physical harm and emotional distress. One resident with a history of paranoid schizophrenia, anxiety disorder, delusional disorder, and personality disorder engaged in aggressive behaviors, including attempting to punch another resident and making verbal threats. This included threatening to slit the throat of another resident, which led to that resident leaving the facility out of fear, embarrassment, and humiliation. The affected resident reported feeling unsafe, which disrupted their rehabilitation and stroke recovery. Another incident involved the same aggressive resident physically assaulting a cognitively impaired, nonverbal resident with a history of stroke, hemiplegia, apraxia, dysarthria, aphasia, and major depressive disorder. The aggressive resident was observed pushing the nonverbal resident in a wheelchair at high speed, then striking the resident multiple times on the head and shoulders. Witnesses reported that the nonverbal resident was visibly scared, in pain, and left with a scalp bruise and red marks, requiring hospital evaluation. Multiple staff and a housekeeper witnessed the incident, and the nonverbal resident's responsible party confirmed the emotional and physical impact of the assault. The facility's policy required the prevention of all forms of abuse, including resident-to-resident altercations, and mandated staff intervention and protection of residents from harm. Despite these policies, the facility did not prevent or adequately intervene in the repeated aggressive behaviors of the resident with a history of mental health disorders, resulting in physical and psychological harm to two vulnerable residents. Staff interviews and resident accounts confirmed that the incidents were reported to administration, but the affected residents and others in the facility expressed fear and distress due to the ongoing threat posed by the aggressive resident.
Failure to Ensure Staff Competency in Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly those with complex psychiatric and behavioral conditions. Multiple staff members, including LPNs, CNAs, housekeepers, and medication technicians, reported not receiving training on behavioral management, de-escalation techniques, or abuse and neglect prevention. Staff expressed fear and a lack of confidence in their ability to safely care for residents exhibiting aggressive, violent, or self-harming behaviors. Interviews revealed that staff were not provided with guidance or interventions to manage residents with significant behavioral health needs, and some staff were assigned to one-on-one supervision without any relevant training or instructions. Several residents with serious mental illnesses, including schizophrenia, schizoaffective disorder, borderline personality disorder, and a history of substance abuse, exhibited frequent and severe behavioral disturbances. These included physical aggression toward staff and other residents, verbal outbursts, attempts to elope, destruction of property, and expressions of suicidal ideation. Documentation showed that these behaviors were ongoing and that staff and other residents felt unsafe. Despite these incidents, there was a lack of incident reporting, care plan updates, behavior monitoring, and documentation of nonpharmacological or pharmacological interventions in the residents' records. The facility's policies required annual in-service training for nurse aides, including behavioral health, and mandated that training be based on the special needs of the resident population. However, the report found that these policies were not implemented effectively, as evidenced by the lack of staff education and competency in managing behavioral health issues. The facility assessment identified a significant number of residents with behavioral health needs, but staff competencies did not align with these requirements. The absence of appropriate training and support led to repeated incidents where staff were unable to manage resident behaviors, resulting in harm to staff and residents, involvement of law enforcement, and ongoing distress within the facility.
Resident Dignity Violated by LPN's Derogatory Remark
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to respect a resident's dignity by calling the resident "dumb" during an interaction. The incident began when the resident requested a pain pill and subsequently became upset, raising their voice at a Certified Nurse Aide (CNA). The LPN and CNA assisted the resident with a Hoyer lift, during which the resident expressed that the nurse did not care about them. The LPN attempted to reassure the resident but ultimately responded to the resident's question about being dumb by saying, "are you dumb, no you are not," though the resident did not understand the response. Multiple witness statements confirmed that the LPN used the word "dumb" in reference to the resident, and the resident reported feeling hurt and upset by the comment, stating that being called dumb was particularly painful due to past experiences. Further witness accounts indicated that the LPN engaged in an argument with the resident, accusing the resident of making negative reports to management. The LPN was reported to have raised their voice, told the resident not to ask for anything further, and made additional derogatory remarks. The resident was visibly upset, expressed a desire to change rooms to avoid the LPN, and reported the incident to the facility's administration. Staff who interacted with the resident after the incident observed that the resident was crying, angry, and emotionally distressed, which was noted to be out of character for the resident. The facility's policy on resident rights, which mandates that all residents be treated with dignity and respect, was not followed in this instance. The Interim Director of Nursing acknowledged that calling a resident dumb would be a violation of the resident's dignity. The incident was reported and investigated, with staff and administrative interviews confirming the resident's account and the inappropriate conduct of the LPN.
Failure to Maintain Full-Time DON and Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis for a period of time. Review of facility policies and the facility assessment confirmed that the expectation was to have a full-time DON, who is a RN, and to employ RNs for at least eight hours daily, every day of the week. Interviews with the Administrator, DON, LPNs, Social Services Director, Assistant Director of Nursing (ADON), and Administrator in Training (AIT) consistently revealed that the facility was without a full-time DON from the termination of the previous DON until the hiring of the new DON, and that RN coverage for the required hours was not consistently provided. The ADON, who is an LPN, filled in for some DON duties during this period, but was not a RN. Employee records confirmed the gap in DON coverage, with the previous DON terminated and the new DON starting nearly a month later. Staff interviews indicated that during this period, RN coverage was supplemented only occasionally by agency staff, and there were times when no RN was present in the facility for the required hours. Staff would sometimes call the previous DON or a PRN DON for guidance when needed, but this did not meet the requirement for on-site RN coverage or a full-time DON.
Failure to Follow Proper Discharge Procedures and Notification Requirements
Penalty
Summary
The facility failed to follow the required process for discharging a resident, specifically neglecting to reassess the resident and properly identify and document how the facility could not meet the resident's needs. The resident in question had a history of morbid obesity, localized edema, depression, anxiety, reduced mobility, and was bedbound. The resident required significant assistance with activities of daily living and had recently experienced a decline in condition, resulting in hospitalization. Despite these complex needs, the facility did not provide the necessary documentation or notification regarding the resident's needs, appeal rights, or bed-hold policies at the time of discharge. Upon the resident's transfer to the hospital, the facility failed to send appropriate discharge paperwork and did not issue a proper 30-day notice of discharge. The hospital attempted to return the resident to the facility, but the facility refused to readmit the resident, citing inability to meet the resident's care needs due to increased weight and lack of appropriate equipment and staffing. Communication between the hospital and the facility was inadequate, with the facility not responding to multiple attempts by the hospital to coordinate the resident's return. Interviews with facility staff confirmed that the decision not to readmit the resident was based on the facility's inability to care for the resident's increased weight and complexity of care. Staff acknowledged that a 30-day notice and appropriate placement should have been arranged prior to discharge, but these steps were not taken. The facility also did not reassess the resident for possible readmission after the hospital transfer, and no evidence was provided that the resident received required notifications regarding appeal rights or bed-hold policies.
Failure to Document and Notify Physician of Missed Medications and Incomplete Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that physician notification was completed and documented regarding missed medications for two out of four sampled residents, and did not ensure blood pressure monitoring was completed for a resident with a physician's order to administer medication based on blood pressure readings. Facility policy required that medications be administered according to physician orders, and that any withheld, refused, or late medications be properly documented on the Medication Administration Record (MAR), with notification to the physician and documentation in the progress notes. For one resident with diagnoses including hypothyroidism and hypertensive heart disease, there were multiple instances where levothyroxine was not documented as given, and no blood pressure readings or administration of midodrine (ordered as needed for hypotension) were recorded over the review period. There was no documentation in the progress notes regarding the reasons for missed doses or any notification to the physician about these missed medications. The resident reported that nurses often did not give all prescribed medications and did not take blood pressure readings as required for medication administration. Another resident with epilepsy, schizoaffective disorder, and violent behaviors had several missed doses of antipsychotic medications (quetiapine and Zyprexa) that were not documented as given on the MAR. Interviews with staff confirmed that the expected procedure was to notify the pharmacy, DON, and physician when medications were not available or not administered, and to document these actions in the progress notes. However, there was no evidence that these procedures were followed, and the facility lacked a system for routine review of MARs for missed medications.
Failure to Verify and Document G-Tube Placement Prior to Use
Penalty
Summary
The facility failed to ensure and document the correct measurement and verification of gastrostomy tube (G-tube/PEG tube) placement prior to administering fluids, medications, and feedings for two residents. Observations showed that an LPN administered water flushes and medications through the G-tubes of both residents without first checking the tube's placement or measuring the external length, as recommended by current clinical guidelines. The LPN did not inspect the tube or verify its position before proceeding with care. Review of the residents' medical records revealed physician orders and medication administration records specifying the use of G-tubes for enteral feeding and medication administration. However, there was no documentation that tube placement was checked or verified prior to these procedures. The LPN admitted during an interview that placement was not checked and stated that the outdated method of injecting air and auscultating was the only method known, and was unaware of the current standard of measuring tube length at the entry point. Further interviews with facility leadership, including the Assistant Administrator and Assistant Director of Nursing, confirmed a lack of knowledge regarding the correct method for verifying G-tube placement. They acknowledged that placement should be checked before use but were unfamiliar with the recommended practice of measuring and documenting the tube's external length. Additionally, the facility was unable to provide a policy for administration of medication via G-tube when requested.
Facility Fails to Maintain Cleanliness and Proper Food Storage Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage standards in the kitchen and food preparation areas. Observations revealed a heavy buildup of debris, including cups, paper, dust, and food debris behind and under the ice machine. Additionally, there was a heavy buildup of dust on the fan over the door across from the coffee station. Two bottles of soy sauce that required refrigeration after opening were found stored on a lower shelf instead of being refrigerated. A bowl of an unidentified yellow substance was found in the kitchen reach-in refrigerator without proper wrapping. Three cutting boards were observed with numerous stains and grooves, making them not easily cleanable, and three spatulas were found frayed or split open. Black debris was present on the pipes behind the dishwasher, and debris was found under the six-burner stove. Containers with brown and clear liquids were not labeled, and the blower vent cover over the door across from the coffee maker station had a heavy buildup of dust. The sprinkler heads were also found with grease buildup. Interviews with the Dietary Manager (DM) and Dietary Cook (DC) revealed that the DM had taken over management of the kitchen recently and was unaware of the condition of the pipes behind the dishwasher. The DM acknowledged that dietary staff should inspect the cutting boards and that an in-service regarding the cutting boards had not been conducted. The DM also stated that dietary staff were expected to clean behind and under the ice machine every night, clean the blower vent cover weekly, use labels for substances that were not easily identified, and follow the labels on condiment containers. The DM expected the night shift staff to clean and mop before leaving for the evening and to cover and protect food in the refrigerator. The spatulas should have been replaced when they started getting frayed. The DC admitted to placing syrup in a bottle without labeling it.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to provide the required nurse aide in-services that included dementia care and abuse prevention training for three sampled CNAs (CNA B, H, and J) from April 2023 through April 2024. The facility's policy mandated that all nurse aides participate in regularly scheduled in-service training classes, including at least 12 hours of training per year, covering topics such as dementia management and abuse prevention. However, the review of the facility's in-service training attendance records revealed that several training sessions were either not attended by the CNAs or no training records were provided for certain months. Specifically, CNA B, H, and J missed multiple training sessions, and there were no records for several months, indicating a lack of consistent training offerings by the facility. Interviews with facility staff, including the Incoming Administrator, Certified Medication Technician B, CNA D, CNA E, the Staffing Coordinator, and the DON, confirmed the inconsistencies in training. The Incoming Administrator acknowledged that the sign-in sheets provided were incomplete and that if staff did not sign in, it was assumed they did not receive the training. CNA D and CNA E reported not attending any in-service training since their employment at the facility, with CNA E specifically noting the absence of abuse, neglect, exploitation, or dementia training. The DON admitted that in-services had not been consistently offered in the past year and that the documentation of training hours was lacking. The facility's failure to provide the required in-service training for dementia care and abuse prevention for the sampled CNAs highlights a significant deficiency in ensuring that nurse aides have the necessary skills to care for residents. The lack of consistent training offerings and incomplete documentation of training attendance contributed to this deficiency, as confirmed by multiple staff interviews and the review of training records.
Failure to Manage Resident Funds Properly
Penalty
Summary
The facility failed to ensure residents who allowed the facility to manage their funds received interest payments and did not have signed authorization forms for three residents. Review of bank statements from April 2023 through March 2024 showed no interest payments. The Corporate Director of Fiscal Services confirmed the absence of interest and was unaware of any changes to the account. Additionally, there were no authorization forms found for three residents, all of whom had legal guardians. The Business Office Manager, who started in January 2023, stated that authorization forms were typically placed behind guardianship paperwork but could not locate them for these residents.
Facility Fails to Maintain Water Temperature, Cleanliness, and Equipment
Penalty
Summary
The facility failed to maintain the water temperature at the handwashing faucets in resident rooms 517, 520, and 523 at or above 105°F. Observations showed water temperatures ranging from 84.5°F to 103.1°F, which were below the required standard. The Maintenance Director admitted to not allowing the water to run for at least two minutes during temperature testing, which contributed to inaccurate readings. This deficiency potentially affected at least 30 residents who resided in those areas or used those facilities. Additionally, the facility failed to maintain the cleanliness of sprinkler heads in the therapy area, Main Dining Room, and side Dining Room, as well as the nurse's station, where dust was observed. The facility also failed to maintain two stand-up lifts, which had cracks in their bases. Staff members, including CNAs and the Maintenance Director, acknowledged the presence of these issues but did not take immediate corrective actions. The Director of Nursing indicated that staff were expected to report and create work orders for damaged equipment, but this protocol was not consistently followed, leading to the continued use of the damaged lifts.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the ombudsman of resident discharges/transfers for three residents out of 17 sampled residents. The facility's policy on transfer and discharge did not include the requirement to notify the ombudsman. Specifically, Resident #48 was sent to the hospital due to seizures and returned to the facility, but the ombudsman was not notified. Similarly, Resident #23 and Resident #268 were discharged to the hospital with their return anticipated, but the ombudsman was not informed of these transfers either. An email from the ombudsman indicated that they had not received transfer/discharge logs from the facility since September 2023. During an interview, the Social Services Designee (SSD) revealed that they had been working in the role for about six months and had been emailing the list of resident discharges to an incorrect email address. The outgoing Administrator confirmed that the SSD was responsible for sending the list of discharges/transfers to the ombudsman and that the SSD had been using an incorrect email address. This miscommunication resulted in the ombudsman not being notified of the resident transfers/discharges as required.
Failure to Include Required Therapies in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan reflected the need for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). The resident, diagnosed with Cerebral Palsy, was admitted with orders for PT, OT, and ST evaluations and treatments. However, the care plan only included risks related to falls and the need for assistance due to Cerebral Palsy, without any mention of the required therapies. This omission was identified during a review of the resident's care plans and physician orders, which showed that the therapies had been initiated but not documented in the care plan. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the MDS Coordinator was responsible for writing and updating care plans. The MDS Coordinator admitted that some care plans were not completed or up to date due to a change in the facility's computer systems. The DON confirmed that the MDS Coordinator and department heads were responsible for updating their respective portions of the care plans. This lapse in documentation led to the deficiency noted in the report.
Failure to Update Care Plans and Invite Residents to Meetings
Penalty
Summary
The facility failed to update care plans for five residents with changes in their conditions and needs. Resident #65, who was moderately cognitively impaired, was admitted to hospice care, but the care plan was not updated to reflect this change. Resident #41's care plan indicated the need for IV antibiotics for a wound infection, but the resident was not receiving these antibiotics as observed over several days. Additionally, Resident #37, who was cognitively intact, was not invited to their care plan meeting, and there was no documentation to show that the resident or their family had been invited to any care plan meetings. Resident #13's care plan was last updated several months after admission, with all care plan goals overdue and no indication of whether goals had been achieved or new goals established. Similarly, Resident #19's care plan, which included psychoactive medication for anxiety and agitation, had overdue goals and no updates on goal achievement or new objectives. Resident #52's care plan, which included management for COPD, tracheostomy, hypertension, anxiety, and depression, also showed overdue goals with no updates or new objectives. Interviews with the MDS Coordinator and the DON revealed that care plans should be completed upon admission, quarterly, with any significant change, and annually. However, due to a change in computer systems, some care plans were not done or up to date. The MDS Coordinator and DON acknowledged that care plans were overdue and that there was no documentation of resident or family invitations to care plan meetings. The DON also noted that anyone on the Interdisciplinary Team could update care plans, but this was not consistently done.
Unqualified Activity Director
Penalty
Summary
The facility failed to have an activity program directed by a qualified Activity Director. The current Activity Director, who also handles Human Resources and Medical Records, did not meet the qualifications outlined in the facility's job description. The job description required a high school diploma or GED, two years of experience in a social or recreational program within the last five years, or completion of a state-approved training course. However, the Activity Director only had a high school diploma, was a Certified Nursing Assistant (CNA) and a Certified Medication Technician (CMT), and had been working part-time in activities for about a year without any formal training in activities or completion of the Activity Director class. The outgoing Administrator confirmed that the individual did not meet all the necessary requirements for the position. During interviews, the Activity Director admitted to not having any training in activities and not having taken the Activity Director class. The outgoing Administrator also acknowledged that while there was an Activities Director certificate available, the current Activity Director had not completed it. This lack of proper qualifications and training for the Activity Director role led to the deficiency identified by the surveyors.
Failure to Provide Ordered Restorative Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Aide (RA) services were provided as ordered to prevent further decline of Range of Motion (ROM) for three residents. Resident #2, diagnosed with Cerebral Palsy, was supposed to receive RA services three times a week, but records showed that the resident only received services twice a week. The Director of Nursing (DON) and other staff members were unsure if the resident was receiving the required RA services, and the RA admitted to being frequently pulled to work as a Certified Nursing Assistant (CNA), which impacted the delivery of RA services. Resident #61, who had Hemiplegia and Hemiparesis following a stroke, was supposed to receive RA services five times a week for upper extremity exercises and splint management. However, there was no documentation of RA services being provided in March, and only four instances of RA services in April. Observations showed that the resident's hand braces were not applied as required, and staff interviews confirmed that the RA was often pulled to work as a CNA, leading to a lack of consistent RA services. Resident #37, with diagnoses including difficulty in walking and osteoarthritis of the knee, was supposed to receive RA services two to three times a week for upper extremity exercises. Documentation showed that the resident received minimal RA services, with several missed opportunities and instances of refusal without follow-up attempts. Interviews with staff and the resident indicated that the RA was frequently pulled to work as a CNA, resulting in inconsistent delivery of RA services. The DON acknowledged that the RA should have documented and performed the required services, but the RA was often reassigned to CNA duties.
Failure to Maintain and Sanitize Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents, specifically in the maintenance and sanitation of oxygen tubing and nebulizer equipment. Resident #33, who has COPD, was observed with a nebulizer mouthpiece that was not stored in a bag and had a brown tinge around it. The resident was unaware if the staff ever washed the mouthpiece. Resident #268, who has CHF and COPD, had undated oxygen tubing and CPAP machine tubing that was not stored in a bag. The resident had not used the CPAP machine for a couple of weeks due to the absence of a mask and was unsure when the oxygen tubing was last changed. Resident #267, who also has COPD, had a nebulizer mask that was not stored in a bag or dated, and the resident had not seen the staff clean the mask since starting to use the nebulizer a few days ago. Resident #17, who has COPD and is on oxygen therapy, had oxygen tubing that was not stored in a bag or dated, and the resident declined to talk about it. Interviews with staff revealed inconsistencies and misunderstandings regarding the responsibilities for changing and cleaning respiratory equipment. LPN A stated that night CNAs were responsible for changing oxygen tubing weekly and that all oxygen equipment should be stored in a clean bag with the date written on it. CNA F mentioned that CNAs changed the oxygen tubing every few weeks and that nurses were responsible for cleaning nebulizer and CPAP masks. The Director of Nursing indicated that oxygen tubing should be changed weekly and stored in a clean bag with the date, and that nurses were responsible for cleaning CPAP and nebulizer masks after each use. The facility's failure to adhere to proper protocols for changing and cleaning respiratory equipment led to unsanitary conditions and potential risks for residents with respiratory conditions. The lack of a clear and consistent policy, as well as the absence of proper documentation and storage practices, contributed to the deficiencies observed during the survey.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was providing services for at least eight consecutive hours a day, seven days a week. The facility had a census of 67 residents. The RN Coverage policy was requested but not provided at the time of exit. The facility's Staffing policy, dated April 2007, indicated that licensed RN staff were available to provide and monitor the delivery of resident care services. However, the Center for Medicare and Medicaid Services (CMS) Staffing Reports from April 1 to December 31, 2023, showed the facility triggered for a One Star Staffing Rating and excessively low weekend staffing. The facility's current employee list showed three RNs employed, including the Director of Nursing (DON), a Regional Director of Nursing PRN, and another RN. The staffing schedule from April 1 to April 14, 2024, revealed that on April 4, 2024, the DON was out of the facility, and no other RN was on the staffing schedule for that day. Interviews conducted on April 19 and April 22, 2024, confirmed the lack of RN coverage. The Staffing Coordinator stated that there was no RN in the building on April 4, 2024. The DON admitted that while there was always RN coverage from Monday to Friday, there was generally no RN at the facility on weekends, and he/she was on-call every other weekend. The DON acknowledged that there should be an RN in the building for at least eight hours a day, every day of the week, but this requirement was not consistently met.
Failure to Respond to Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the Medication Regimen Review (MRR) was responded to for four sampled residents out of 17 sampled residents. The Consultant Pharmacist made recommendations regarding medication adjustments and assessments, but there were no documented responses from the physicians in the residents' electronic health records. This lack of response was observed for residents with complex medical histories, including mental health conditions and chronic pain, who were on multiple psychotropic and pain medications. For Resident #42, the Consultant Pharmacist recommended a gradual dose reduction (GDR) of psychotropic medications and the completion of the Abnormal Involuntary Movement Scale (AIMS) assessment. However, there was no response to these recommendations in the resident's electronic health record. Similarly, Resident #19 had no AIMS reports available despite the pharmacist's recommendation to update the AIMS assessment every six months due to antipsychotic use. Resident #24's MRRs showed repeated recommendations for dose reduction or discontinuation of certain medications, but there were no responses from the physician. Resident #41 had a potential duplicate order for pain medications, and again, there was no response from the physician. Interviews with facility staff revealed a lack of clarity and follow-through in the process of handling MRRs, with the Director of Nursing (DON) acknowledging that physicians should respond to all recommendations but failing to ensure this was consistently done.
Failure to Monitor Medication Refrigerator Temperatures and Remove Expired Medications
Penalty
Summary
The facility failed to monitor the medication refrigerator temperatures and remove expired medications in the Rehabilitation Unit. Observations revealed that the temperature log for the medication refrigerator was blank from January through April 18, 2024. Additionally, expired medications, including Acetaminophen suppositories with an expiration date of January 2023 and glycerin suppositories with an expiration date of March 7, 2024, were found in the refrigerator without open dates recorded. Interviews with staff members, including LPNs and CMTs, indicated a lack of knowledge regarding who was responsible for filling out the temperature log and checking for expired medications. The Director of Nursing (DON) confirmed that the night shift nursing staff was responsible for monitoring and recording the medication refrigerator temperatures daily. The DON or the Assistant DON (ADON) were supposed to audit the temperature logs to ensure compliance. The DON also stated that either he/she, the ADON, or a designee was responsible for auditing expired medications in the medication refrigerator and medication carts. However, the observations and staff interviews indicated that these procedures were not being followed, leading to the presence of expired medications and unmonitored refrigerator temperatures.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure that four residents with broken or missing teeth were seen by a dentist. Resident #37 had broken dentures and had not seen a dentist since being admitted to the facility. Despite informing the nurse about the need for dental care, no action was taken. The resident's care plan and physician's visit records did not reflect any dental issues, and staff were unaware of the resident's need for denture repair. Resident #53 had broken teeth and had signed an authorization for dental care, but had not seen a dentist in over a year and a half. The resident expressed a desire to have all teeth pulled and dentures made, but no dental appointment was scheduled. The care plan and physician's orders did not indicate any dental issues, and staff were unaware of the resident's dental needs. Resident #267 had no top teeth and some bottom teeth, but had not seen a dentist in the 11 months of being at the facility. The resident had informed the nurse about the need for dental care, but no action was taken. Similarly, Resident #32 had broken or missing teeth and had not seen a dentist since admission. The resident had requested dental care, but no appointment was scheduled. The care plans for these residents did not address their dental issues, and staff were unaware of the need for dental appointments.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Two residents, who were cognitively intact, reported receiving cold food almost every day and raised the issue during resident council meetings. The Dietary Manager (DM) acknowledged the problem but did not take effective measures to address it. Observations during meal service showed that hot foods were not maintained at the required temperature of 120 F, and cold foods were not kept at or below 41 F. For instance, a burger sandwich and tater tots were served at temperatures significantly below the required levels, and pineapple chunks were served at 59.5 F, which is 18 degrees above the acceptable limit. The DM admitted to not monitoring food temperatures at the point of service and was unaware of the required temperature standards for serving food to residents. Further observations and interviews revealed that the issue was particularly prevalent among residents receiving room trays. Staff members, including Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs), confirmed that they had not seen anyone from the dietary department checking the temperatures of room trays. The DM also confirmed that the dietary staff only took temperatures at the first serving of food and not at the last serving. This lack of monitoring and adherence to temperature standards led to residents consistently receiving cold meals, which was a significant concern raised during resident council meetings and individual interviews.
Failure to Implement Plan of Correction
Penalty
Summary
The facility's administration failed to implement a plan of correction (POC) by the designated date, resulting in continued deficient practices that potentially affected the residents' physical, mental, and psychosocial well-being. The facility had a census of 64 residents at the time of the survey. The Administrator policy, dated April 2007, outlined that a licensed Administrator was responsible for the day-to-day functions of the facility, serving as a liaison to the governing board, medical staff, and other professional and supervisory staff, and for the evaluation and implementation of recommendations from the facility's Quality Assessment and Assurance Committee. However, the facility failed to complete 12 out of 16 required audits, including those for Ombudsman notifications, Medication Administration Records (MAR)/Treatment Administration Records (TAR), resident baths/showers, the Restorative Program, resident weights, oxygen, dialysis, psychotic medications, expired medications, dental appointments, food temperatures, and resident vaccines. During an interview, the Corporate Administrator revealed that many of the completed audits went missing when the previous administrator abruptly left the position about two weeks prior. The previous administrator had sent an email and left the next day, leading to a lack of continuity and knowledge about the audit process. As a result, the audits were not conducted in the last two weeks, contributing to the facility's failure to implement the POC by the correction date. This lapse in administrative oversight and audit completion directly led to the continued deficient practices within the facility.
Failure to Complete and Monitor QAPI Audits
Penalty
Summary
The facility failed to identify and correct quality deficiencies through its Quality Assurance and Performance Improvement (QAPI) plan, leading to continued deficient practices that potentially affected the residents' physical, mental, and psychosocial well-being. The facility's QAPI program was designed to establish data-driven processes to improve the quality of care and life for residents, but it was not effectively implemented. Specifically, the facility did not complete 12 out of 16 required audits, including those for ombudsman notifications, medication administration records, resident baths/showers, restorative programs, resident weights, oxygen, dialysis, psychotic medications, expired medications, dental appointments, food temperatures, and resident vaccines. During an interview, the Corporate Administrator revealed that many completed audits went missing when the previous administrator abruptly left the position about two weeks prior. The previous administrator's sudden departure left the facility without knowledge of the audit process, resulting in the audits not being conducted in the last two weeks. This failure to complete and monitor the audits as part of the QAPI process contributed to the ongoing deficient practices within the facility, affecting the overall quality of care provided to the residents.
Failure to Conduct TB Testing for Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not providing Tuberculosis (TB) testing for five sampled residents. The facility's policy required TB screening for all residents, including a two-step TB skin test (TST) upon admission if no prior documentation existed. However, the records for Residents #33, #48, #60, #61, and #173 showed no evidence of TB testing or screening as per the facility's policy. Interviews with the outgoing administrator, Licensed Practical Nurses (LPNs), and the Director of Nursing (DON) revealed that the responsibility for administering TSTs was assigned to nurses, but the tests were not conducted or documented properly. Resident #33 had a documented first and second step TST in late 2019 and early 2020, but no further TB screenings were provided after January 2021. Resident #48 had an order for an annual Purified Protein Derivative (PPD) test, but no PPD was given as per the March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR). Resident #60's hospital discharge paperwork indicated no current TB symptoms or contact, but there were no physician orders or records for a TST or screening. Resident #61 and Resident #173 also lacked physician orders and records for TB testing or screening. The outgoing administrator admitted to being unaware that TSTs were not being done, and the DON confirmed that no one tracked when the TSTs were given or read. The facility's failure to follow its own TB screening policy and ensure proper documentation led to the deficiency in maintaining an effective infection prevention and control program. The lack of TB testing and screening for the sampled residents indicated a significant lapse in the facility's adherence to its infection control protocols.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not offering pneumococcal and influenza vaccines to five sampled residents. The facility's policies required that all residents be offered these vaccines unless medically contraindicated or previously vaccinated, and that documentation of the offer, acceptance, or refusal be maintained in the resident's medical record. However, the facility did not provide records showing that the vaccines were offered or administered to Residents #33, #48, #60, #61, and #173, nor did they document any medical contraindications or refusals for these residents. Resident #33, who was cognitively intact and diagnosed with COPD, stroke, and hemiplegia, had no records of being offered or receiving the pneumonia vaccine. Resident #48, who was severely cognitively impaired, also had no records of being offered or receiving the pneumonia vaccine. Resident #60, who was cognitively intact and had type 2 diabetes, hemiplegia, and obstructive sleep apnea, had no records of being offered or receiving either the pneumococcal or influenza vaccines. Resident #61, who was severely cognitively impaired and had acute respiratory failure, a tracheostomy, and hemiplegia, had no records of being offered or receiving either vaccine. Resident #173, who was admitted following joint replacement surgery and had obstructive sleep apnea, also had no records of being offered or receiving either vaccine. Interviews with facility staff revealed that the responsibility for offering and documenting vaccinations was assigned to the admitting nurses, but there was a lack of follow-through and oversight. The outgoing administrator admitted to being unaware that the immunizations were not being done, and the Director of Nursing acknowledged that the expected documentation and follow-up were not completed. This failure to adhere to the facility's vaccination policies resulted in the deficiency noted by the surveyors.
Failure to Provide and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases by not providing the COVID-19 vaccine to three sampled residents. Resident #60, who was cognitively intact and had conditions such as Type 2 diabetes and obstructive sleep apnea, had no orders for a COVID-19 vaccine and no records of being offered the vaccine or education regarding its risks and benefits. Similarly, Resident #61, who was severely cognitively impaired and had acute respiratory failure and a tracheostomy, also had no orders for the COVID-19 vaccine and no records of being offered the vaccine or education. Resident #173, admitted with diagnoses including aftercare following joint replacement surgery and obstructive sleep apnea, had no orders for the COVID-19 vaccine and no records of being offered the vaccine or education either. The facility census was 67 residents at the time of the survey. Interviews with facility staff revealed inconsistencies and gaps in the process of offering and documenting COVID-19 vaccinations. The Outgoing Administrator admitted to being unaware that COVID-19 immunizations were not being done and mentioned that the responsibility had been shifted to the nurses without proper follow-up. The Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) provided conflicting accounts of the vaccination process, with some stating that the ADON usually handled vaccinations and others indicating that the admitting nurse was responsible. The Director of Nursing (DON) confirmed that the COVID-19 vaccine and education were supposed to be offered to all new residents, but the process was not consistently followed, and documentation was lacking. The facility's policies on vaccination and infection control were not adhered to, leading to a failure in offering and documenting COVID-19 vaccinations for the sampled residents. The lack of a systematic approach and clear responsibility for administering and documenting vaccinations contributed to this deficiency. The facility's failure to provide the COVID-19 vaccine and proper education to the residents compromised the infection prevention and control program, as evidenced by the missing documentation and inconsistent practices among the staff.
Failure to Update Resident's Code Status to DNR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately updated from full code to Do Not Resuscitate (DNR). Resident #61 was admitted with a full code status, but an advance directive dated 2/8/24 indicated a DNR status. Despite this, the resident's care plan dated 3/13/24 and the Physician's Order Sheet (POS) dated April 2024 still reflected a full code status. Interviews with staff revealed that the admitting nurse was responsible for ensuring the resident's wishes were reflected on the chart, but this was not done. Additionally, there was no clear process for auditing residents' charts to ensure the most up-to-date code status was documented. The Assistant Director of Nursing (ADON) acknowledged that the resident's code status should have been changed to DNR once the advance directive was received from the family, but this was missed. The Director of Nursing confirmed that the admitting nurse was responsible for ensuring the resident had a code status upon admission and that it should be listed on the face sheet and POS. The failure to update the resident's code status was a significant oversight, as it did not align with the resident's documented treatment preferences and advance directive.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to provide two residents with a written summary of a baseline care plan within 48 hours of their admission. For Resident #41, the nursing admission screening was partially completed, missing critical information such as medications and the identity of the person who completed the screening. The resident reported not knowing anything about a care plan, and the Director of Nursing (DON) confirmed that the baseline care plan was not done. Similarly, for Resident #60, although a baseline care plan form was completed, it lacked signatures and evidence that the resident was provided with a copy. The resident also reported not being aware of a baseline care plan meeting. Interviews with the DON, Assistant DON, and MDS nurse revealed that the baseline care plans were typically done in the resident's room but were not being printed, signed, or provided to the residents or their families. The facility's policy required a baseline care plan to be developed within the first 48 hours of admission to meet the resident's immediate care needs, but this was not adhered to in these cases. Both residents had significant medical needs, including wounds, high-risk medications, and mobility impairments, which were not adequately addressed due to the lack of a proper baseline care plan.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately document the administration of pain medication for one resident and ensure another resident had taken their prescribed medications. For Resident #41, the facility's records showed discrepancies in the administration of Oxycodone. The Medication Administration Record (MAR) indicated that the medication was not administered on two specific dates, but the narcotic count sheet showed it was given 26 more times than documented on the MAR. Interviews with the LPN and the Director of Nursing (DON) confirmed that proper documentation was not maintained, and there were no nurses' notes explaining the discrepancies on the MAR. For Resident #33, the facility failed to ensure the resident took their prescribed medications. Observations revealed that the resident had pills left at their bedside, which they had forgotten to take. The resident confirmed that the nurse had left the pills the previous night. The facility's policy and interviews with staff, including a Certified Medication Technician (CMT) and an LPN, indicated that medications should not be left at the bedside without a physician's order, and staff should observe the resident taking the medication. The DON confirmed that the resident did not have an order to leave medications at the bedside and that staff should have ensured the medications were taken. These deficiencies highlight the facility's failure to adhere to its medication administration policies, leading to improper documentation and potential risks for the residents involved. The lack of proper documentation and failure to ensure medication intake could have serious implications for resident care and safety.
Failure to Ensure Weekly Showers for Residents
Penalty
Summary
The facility failed to ensure that bathing/showers were completed at least once weekly and according to the residents' preferences for two sampled residents out of 17. Resident #13, who had diagnoses including colostomy status and essential hypertension, did not have shower sheets for multiple weeks between 3/1/24 and 4/13/24. The resident expressed a preference for weekly showers, and a CNA confirmed that the resident usually did not refuse showers. Similarly, Resident #54, with diagnoses including essential hypertension and unspecified glaucoma, did not have shower sheets for specific weeks and reported not receiving a shower between 3/30/24 and 4/12/24. The resident also preferred weekly showers and kept track of activities in a notebook, confirming the missed showers. A CNA corroborated that the resident seldom refused showers and liked them regularly. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the shower schedule and documentation. The facility had two shower aides responsible for giving showers twice a week, but there were gaps in coverage and documentation. The DON stated that residents should be offered showers at least weekly, and shower sheets should be filled out even if a resident refused. However, the audit process by the ADON did not catch these deficiencies, leading to missed showers for the residents. The facility's shower policy lacked specific guidelines on the frequency of showers, contributing to the oversight.
Failure to Complete Physician-Ordered Weekly Weights for Resident
Penalty
Summary
The facility failed to ensure physician-ordered weekly weights were completed for a resident who had lost weight and was receiving tube feeding. The resident, who had multiple diagnoses including respiratory failure, hemiplegia following a stroke, gastrostomy status, and tracheostomy status, was admitted to the facility and required weekly weight monitoring as per physician orders. Despite this, there was no documentation of the resident's weight from early March to mid-April, during which the resident experienced a significant weight loss of 5.55% over three months. Interviews with staff revealed that the responsibility for weighing residents fell to Restorative Aides (RAs), who were sometimes reassigned to work as Certified Nursing Assistants (CNAs) on the floor, leaving the weighing tasks uncompleted. The Director of Nursing (DON) confirmed that residents with feeding tubes should have been weighed weekly and that the weights should have been documented in the computer system. However, due to the reassignment of RAs and lack of follow-up by other nursing staff, the required weekly weights were not consistently performed or recorded.
Failure to Ensure Proper Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration with the dialysis center for a resident with end-stage kidney disease. The facility's policy on the care of residents with end-stage renal disease did not address communication protocols between the facility and the dialysis center. This deficiency was identified during a review of the care plan and physician's orders for a resident who was cognitively intact and received dialysis twice a week. The Director of Nursing (DON) and Assistant DON confirmed that the facility did not have the resident's dialysis sheets, which were supposed to be filled out by the nurse before the resident went to dialysis and returned with the resident after the session. The DON and Assistant DON stated that if the dialysis form did not come back with the resident, the nurse should document the information in a nurse's note or call the dialysis facility. However, this procedure was not followed, as evidenced by the missing dialysis sheets and lack of documentation. The facility's failure to ensure proper communication and documentation regarding the resident's dialysis care led to this deficiency being cited by the surveyors.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure psychotropic medications were administered for specific conditions and that PRN orders were limited to 14 days without review. For one resident, the facility did not have documented physician rationale for the use of Lorazepam, and the medication was not re-evaluated after 14 days. The Assistant Director of Nursing (ADON) acknowledged that the nurse should call the physician to clarify diagnoses for medications like Amitriptyline and Depakote, and that PRN antianxiety medications should be re-evaluated after 14 days. However, this process was not followed, leading to a deficiency in medication management for the resident involved. Another resident did not receive a gradual dose reduction (GDR) for psychotropic medications despite recommendations from the pharmacist. The pharmacist had reviewed the resident's medications, including Duloxetine and Lurasidone, and requested a dose reduction or discontinuation multiple times. However, there was no documented response from the physician to these recommendations. The Director of Nursing (DON) confirmed that the pharmacist's recommendations should be addressed and signed by the physician, but this was not done, resulting in a failure to follow through on the GDR process. Interviews with facility staff, including the DON and ADON, revealed that the facility had policies in place for medication management and MRRs, but these were not consistently followed. The DON admitted that the process for reviewing new admission medication orders was not official, and the ADON stated that they usually monitored PRN orders for antianxiety medications. The lack of adherence to these policies and procedures led to deficiencies in the administration and management of psychotropic medications for the residents involved.
Failure to Close Dumpster Lids
Penalty
Summary
The facility failed to ensure the lids of the dumpsters were closed after staff placed trash in them. This deficiency was observed on multiple occasions: on 4/15/24 at 9:59 A.M. and 11:21 A.M., both outdoor dumpsters were left open; on 4/16/24 at 2:20 P.M., two lids of one dumpster were left open; and on 4/17/24 at 12:36 P.M., the lids of both dumpsters were left open. During an interview on 4/17/24 at 12:38 P.M., the Dietary Manager stated that all departments within the facility were expected to keep the dumpsters closed to prevent raccoons from accessing the trash.
Facility Failed to Maintain Exterior Siding, Creating Pest Entry Points
Penalty
Summary
The facility failed to maintain the siding on the outside of the former dementia unit and the siding on the outside wall behind the kitchen in good repair, creating openings that pests could get into. On 4/15/24, a bird was observed entering one of the gaps in the missing siding on the outside wall of the dementia unit. On 4/16/24, the Maintenance Director confirmed that an approximately 6 feet wide by 2 feet high section of siding behind the air conditioning unit outside the kitchen was damaged, with visible insulation. The Maintenance Director stated that the damage existed before his tenure and was exacerbated by water from a damaged downspout. Additionally, a 47 feet long section of siding on the outside wall of the former dementia unit was observed to be damaged with several gaps. The Maintenance Director confirmed that this damage also predated his tenure, which began in February 2022.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment and documentation. One resident, who was admitted to hospice services prior to facility admission, developed a facility-acquired pressure ulcer on the coccyx that became infected, requiring antibiotic therapy. The facility did not conduct weekly skin assessments or document the wound's stage, measurements, or characteristics in the resident's electronic medical record (EMR). Additionally, the resident's care plan did not address the pressure ulcer or its infection, and there was no physician's order for the use of calcium alginate, which was used without proper documentation. Another resident was admitted with unstageable pressure ulcers on the ischial areas, but the facility failed to perform weekly skin assessments or document the wounds in the EMR. The resident's care plan indicated the need for weekly skin assessments, but these were not completed. The facility's Weekly Wound Report did not include the resident's pressure ulcers, and there was a lack of progress notes describing the wounds' stage, measurements, or characteristics. The facility's wound nurse mistakenly believed that hospice nurses were responsible for documenting the residents' wounds, leading to a lack of proper documentation and tracking of the pressure ulcers. The wound nurse did not enter assessments in the EMR or on the Weekly Wound Report, and the facility's Director of Nursing and Administrator were unaware of the residents' pressure ulcers until questioned by the state surveyor. The facility's failure to adhere to its wound care policy and ensure proper documentation and assessment of pressure ulcers resulted in deficiencies in the care provided to these residents.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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