Grove At Kirkwood, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Kirkwood, Missouri.
- Location
- 711 South Kirkwood Road, Kirkwood, Missouri 63122
- CMS Provider Number
- 265833
- Inspections on file
- 22
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Grove At Kirkwood, The during CMS and state inspections, most recent first.
The facility failed to follow physician orders for wound care and compression therapy for two residents with lower extremity wounds. One resident with multiple comorbidities had non‑pressure leg wounds with orders for specific cleansing, skin prep, xeroform, collagen powder, gauze, and Kerlix, as well as XXL knee‑high compression stockings. Observations showed saturated dressings left in place for several days, macerated surrounding skin, omission of ordered products, lack of collagen powder, and repeated failure to apply compression stockings despite an active order. Another resident with CHF, pneumonia, glaucoma, and diabetes had a skin tear on the left lower leg with orders for daily and PRN wound care, but staff did not document treatments for several days, and the dressing remained dated from the initial application. There was also no baseline care plan to guide staff on this resident’s care needs.
The facility failed to maintain required inventories of personal belongings for two cognitively intact residents who reported missing clothing, despite a policy requiring completion and updating of inventory sheets and staff acknowledgment that such forms should be present and scanned into the medical record. A resident with anxiety, DM, and glaucoma did not receive an admission packet on the day of admission and lacked a baseline care plan, with the admission packet only signed later. The facility also used a new admission agreement that did not address prior $6,000 security deposits required under a previous management contract; one resident’s family provided documentation of having paid such a deposit, but subsequent invoices showed no record of a refund after discharge, while leadership reported unawareness of the prior deposit terms and that deposit funds were not turned over during the ownership change.
The facility failed to manage finances and operations in a way that ensured timely payment to key vendors and adequate supplies and staffing for resident care. After a change in ownership, staff reported chronic shortages of wipes, towels, plates, gloves, and incontinence products, with downgraded product quality and no clear departmental budgets. Housekeeping used substitute cleaning chemicals with uncertain dilution, and dietary staff reported the dish machine lacked soap and rinse chemicals for an extended period, leading to hand-washing dishes and serving meals on Styrofoam plates and foam cups despite resident council requests for regular dishware. Corporate-controlled ordering resulted in reduced quantities and substitutions of cheaper food items, while the RD reported not being paid and difficulty working with corporate. Multiple vendors, including primary food suppliers, a staffing agency, an oxygen supplier, pest control, and other service providers, confirmed large unpaid, past-due balances with no payments made under new management. CNAs and LPNs described bounced or incorrect paychecks, missing hours, and unresolved payroll issues, along with frequent short staffing, extended shifts, and nurse turnover, while maintenance and housekeeping staff were reduced and multiple vendors remained unpaid, affecting services throughout the facility.
Surveyors found that the facility failed to complete a thorough facility-wide assessment, leaving all sections documenting monthly average ADL assistance needs (bed mobility, transfers, bathing, eating, toileting, and mobility) blank, despite a census of 91 residents. The assessment contained only general statements about staffing assignments and infection prevention practices and did not quantify resident care needs. During the survey, additional issues were identified, including lack of required 12-hour CNA training in abuse/neglect and dementia care for sampled CNAs, insufficient nursing staff resulting in missed treatments and ADL care, absence of a restorative program and speech therapy, incomplete TB testing for sampled residents, missing EBP signage and PPE for residents on enhanced barrier precautions, and housekeeping staff not using an EPA-registered hospital disinfectant. The administrator acknowledged responsibility and stated the assessment was expected to be fully completed with total numbers of residents requiring assistance.
Surveyors found that staff repeatedly failed to follow infection prevention and control policies, including not implementing Enhanced Barrier Precautions for residents with catheters, wounds, and nephrostomy tubes, not posting EBP signage, and not using gowns during high-contact care. Perineal care was performed on multiple residents with improper glove use and without required hand hygiene, and catheter care was omitted after bowel movements. A shared Hoyer lift was used on two residents consecutively without disinfection between uses. Several newly admitted residents and newly hired employees lacked required two-step TB testing or TB screening documentation. Housekeeping staff used a non–EPA-registered all-purpose cleaner on floors instead of a hospital-grade disinfectant and were unsure of correct dilution, while supply limitations and lack of a housekeeping leader contributed to inconsistent cleaning practices.
The facility did not maintain an active antibiotic stewardship program as required by its own policy. The written policy, dated 7/1/25, called for an antibiotic stewardship program integrated with infection prevention and control, led by the Medical Director, DON, IPC nurse, and consultant pharmacist, with support from the Administrator and governing officials, and intended to optimize infection treatment and reduce adverse events from antibiotic use. However, the Administrator reported that the program had not been updated for many months, the IPC nurse had recently left, and the program had only just been restarted, leaving the facility without established antibiotic use protocols or a system to monitor antibiotic use for its resident population.
The facility did not follow its own policy requiring that COVID-19 vaccines be offered, education provided, and vaccination status documented for all residents. Record review for five residents with significant conditions such as heart failure, kidney disease, asthma, diabetes, osteomyelitis, stroke, and dysphagia showed no documentation that they were offered or received the COVID-19 vaccine, nor that any education or refusals were recorded. The Infection Preventionist stated that vaccines, refusals, and related education are expected to be offered on admission or upon request and documented in the medical record, but this was not done for these residents.
Surveyors identified that an LPN provided hands-on care to a severely cognitively impaired resident while wearing earphones connected to a phone with music playing, and another resident reported that staff frequently had earbuds in and were on their phones during care, despite facility policies prohibiting such device use in resident care areas. In addition, residents reported and resident council minutes documented that they were being served meals on Styrofoam plates with plastic cutlery and foam cups instead of regular dishware and silverware, which they did not feel was homelike. Dietary staff and the Dietary Manager stated the dish machine had been without soap and rinse chemicals for an extended period due to a change in chemical vendors driven by cost concerns, leading to hand-washing of dishes and ongoing use of disposable products, while the Administrator reported not being aware that Styrofoam and plastic were being used in place of reusable dishware.
The facility failed to maintain a safe, clean, and homelike environment for several residents and in a shared shower room. One resident with multiple medical conditions had a crumbling wall and stained ceiling tile around a window that allowed cold drafts into the room for at least two months, as confirmed by staff. Another resident with severe cognitive impairment was found by a family member shivering in bed with an open window, uncovered feet, and an untouched meal from the prior evening; a CNA later admitted opening the window due to odor and heat. A third resident’s room had dusty floors, a missing floorboard under the bed, and fall mats covered with food debris and trash, despite staff expectations that floors be clean and intact. Surveyors also observed a shower room with unlined trash cans containing used briefs, toilets and riser seats smeared with stool and brown matter, puddles of liquid on the floor, no toilet paper, and a strong urine odor, while housekeeping reported once-daily cleaning and leadership stated the area should be clean and adequately supplied.
The facility failed to follow its grievance policy by not investigating or resolving a grievance filed by a cognitively intact resident regarding an incident in a shower room, leaving the grievance form incomplete with no documented findings or resolution. Resident council representatives reported that staff rarely followed up on grievances and that responses took months. Grievance forms and secure submission boxes were not available in common areas as expected, and an Admissions Coordinator could not account for their absence. An LPN and a CNA were unfamiliar with the formal grievance process and only reported concerns to a charge nurse. The newly designated Grievance Official and the Administrator were unaware of the resident’s grievance, despite stating that grievances should be investigated and resolved within a set timeframe and that residents and families should have free access to grievance forms.
The facility failed to provide adequate ADL care, including bathing, nail care, oral hygiene, and assistance out of bed, for multiple residents. One resident with cognitive impairment and multiple comorbidities had no baseline care plan, was observed with oily hair and long, jagged fingernails, and reported not receiving a shower that week. Another cognitively intact, incontinent resident with heart failure, hip fracture, diabetes, and kidney disease, care planned for hands-on ADL assistance, was seen in stained clothing with unkempt hair and reported needing staff help with showers but receiving them infrequently, with missing shower documentation for an entire month. A third resident with muscle weakness and diabetes had no ADL needs in the care plan, was observed with overgrown toenails and caked debris on the teeth, and reported staff would not assist with nail care or toothbrushing, with a CNA citing lack of staffing. A fourth resident with heart and kidney disease, requiring extensive assistance and a Hoyer lift, had no care plan, was repeatedly observed in bed in a hospital gown, and reported wanting to get out of bed and into clothes but believing they were too much work for staff, despite therapy confirming no restrictions and a special wheelchair being available. Staff interviews confirmed expectations for twice-weekly showers or bed baths, hair washing, nail care, oral hygiene, and daily out-of-bed opportunities, which were not consistently met or documented.
Surveyors identified that staff did not follow facility policies for safe transfers and chemical storage. During Hoyer lift transfers for two residents with dementia and severe cognitive impairment who were dependent on staff for transfers, CNAs moved the lift with the legs closed and did not maintain appropriate contact or guidance, contrary to the facility’s Total Lift Transfer policy and staff expectations described by an LPN and the DON. In a separate incident, an LPN transferred a cognitively impaired resident with cardiac conditions from bed to wheelchair by lifting under the arms and pulling on the resident’s pants, without using a gait belt even though gait belts were available in the room, in violation of the facility’s Gait Belt Transfer policy and staff expectations. Additionally, an uncapped bottle of Dakin’s 0.125% solution, labeled for external use only, was repeatedly observed left out and accessible in the room of a cognitively impaired resident, including when the resident was not present, and there was no physician order for this solution.
The facility failed to provide adequate nursing and therapy staffing and proper orientation for new and agency staff, resulting in multiple residents not receiving basic hygiene and therapy services. A resident was observed with oily hair and long, jagged fingernails and reported not getting a shower that week; another incontinent resident, dependent on staff for bathing, was seen in stained clothing and reported infrequent showers despite a twice-weekly schedule and missing shower documentation. A third resident had overgrown toenails and caked debris on the front teeth and reported that staff would not assist with nail care or oral hygiene, requiring family help, while a CNA attributed missed hygiene care to short staffing. Facility records showed no speech therapy services or restorative program over several months, and the rehab director and DON acknowledged the absence of these services. Multiple LPNs reported working without orientation or training, being left to work alone on their first day, and ongoing short staffing, while an LPN and the administrator described heavy reliance on agency staff, limited RN coverage, loss of key nursing roles, frequent leadership turnover, and lack of structured handoff of regulatory duties.
Surveyors found that multiple residents did not receive ordered medications because the facility failed to obtain and administer drugs as prescribed, despite policies requiring timely ordering, use of an E-kit or Pyxis, and prompt transcription of physician orders. One resident with multiple sclerosis and sleep apnea missed most doses of modafinil and Glatopa, with documentation of drugs not available and an incorrect order entry after an EMR change. Another resident with muscle weakness and diabetes missed numerous tramadol doses for pain, while a resident with kidney and respiratory failure missed repeated doses of tramadol and ordered eye drops, which staff documented as unavailable and the resident reported not receiving. A resident with chronic kidney disease and depression did not have a midodrine order or administration documented after the EMR switch, and bags of ordered IV saline labeled for this resident were found unused in the med room. Additional residents with chronic pain, HTN, UTI, CAD, HF, hypothyroidism, PVD, and clotting risks had extensive missed doses of atenolol, Augmentin, statins, thyroid hormone, beta-blockers, midodrine, diuretics, anticoagulants, antiplatelets, and antiarrhythmics, often marked as not available or simply not given. Staff reported problems with the new medication ordering system and inadequate training, while leadership acknowledged that blank MAR entries indicated missed doses and that staff were expected to reorder and escalate after a single missed dose.
The facility failed to reasonably accommodate residents’ needs and preferences by not ensuring call lights were accessible and by not repairing a shower in a timely manner. One resident with severe cognitive impairment and Alzheimer’s disease, care planned to use the call light for assistance due to fall risk, was repeatedly observed in a recliner with the call light wrapped around the bed rail or under a pillow, out of reach, despite staff acknowledging the resident could use the call system and that it should be accessible. Another resident with severe cognitive impairment, dementia, heart disease, and heart failure, dependent on staff for hygiene and care planned to have the call light within reach at all times, was observed in bed while the call light lay on the floor behind the headboard. In addition, a cognitively intact resident with arthritis and spinal stenosis, who used a wheelchair and lacked an in-room bathroom, reported that the 200 hall shower room had been unusable for over a month, forcing use of a more distant shower room; staff confirmed the shower had been broken for about a month and had not yet been repaired.
The facility failed to maintain an effective process to track and refund a required $6,000 security deposit owed to a discharged resident under a prior admission agreement. Under the former management’s contract, a deposit was collected at admission and was to be refunded after discharge, but later invoices contained no record of the deposit. The resident, who had severe cognitive impairment and multiple diagnoses, was transferred to another facility with coordination involving the resident’s daughter. Interviews showed that current leadership, including a Regional Nurse Consultant and the Administrator, were unaware of the prior deposit/refund requirement or the specific deposit, and the current admission agreement did not address handling of deposits collected under the previous management, resulting in the deposit not being identified and returned at discharge.
Surveyors found that the facility failed to ensure safe, coordinated discharge planning for two residents, contrary to its own policy requiring IDT involvement, physician orders, referrals, and discharge summaries. One resident with multiple conditions, including diabetes and visual impairment, reported being told by the SW that it was not her job to find a new placement or assist with an appeal, and therapy staff stated the resident was non-ambulatory, required assistance with ADLs, and was unsafe to manage numerous stairs at home, yet the resident was still discharged after arranging personal transportation. Another cognitively intact resident with several chronic diagnoses was discharged home with medications but had no physician discharge order, no documented discharge planning, referrals, or discharge summary in the record, despite the DON’s stated expectation that such planning and documentation occur.
A resident with moderately impaired cognition and an ileostomy had documented diagnoses including Crohn’s disease and chronic kidney disease, but there were no physician orders or care plan for ostomy care despite facility policy requiring such orders. The resident’s family reported that staff were not assisting with emptying the ostomy bag, leading family members to perform the care and that concerns raised to a DON were not addressed. Two LPNs stated they were unaware the resident had an ostomy, and one LPN found the resident on the floor after an unwitnessed fall, with feces on the floor and the resident holding the ostomy bag after attempting to walk to the bathroom to empty it. The DON later acknowledged expectations that staff be aware of the ostomy, assist with care, and have appropriate orders and care planning, which had not occurred.
Surveyors found multiple failures in medication storage, labeling, and temperature control across several medication carts and a medication room. One cart contained personal items, and a medication refrigerator holding drugs for multiple residents was discovered unplugged and reading well above the required 36–46°F range, with no documented temperature checks for several days. Other nurse and CMT carts held insulin pens without proper labels or open dates, topical medications without resident names or open dates, loose and partially cut pills outside original packaging, expired urine collection tubes, and glatopa syringes labeled for refrigeration but stored on the cart. Staff interviews showed that an LPN did not verify refrigerator checks and was unfamiliar with policy, and the DON acknowledged that insulin pens should be fully labeled and that nurses are responsible for removing medications when residents are discharged.
A resident with multiple comorbidities and significant mobility limitations did not receive consistent in‑house PT or ST despite physician orders, and the facility did not document or care plan the extensive outside PT the resident attended. Following a change in ownership and therapy staffing turnover, PT/OT services were reduced, ST was not offered for several months, and the restorative nursing program was discontinued without replacement. Staff interviews confirmed there was no active restorative program, no in‑house ST, and that therapy coverage was limited, while the DON acknowledged awareness of outside therapy but the lack of corresponding documentation and care planning in the medical record.
A resident with severe pain from neuropathy, recent surgery, and pressure ulcers did not receive prescribed pain medication due to staff inaction and lack of access to the automated drug dispensing system. CNAs reported the resident's pain to an agency nurse, who did not administer the medication or notify facility leadership, resulting in unmanaged pain until the next shift. The facility's pain management procedures were not followed, and the physician was not informed of the issue.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
The facility failed to provide complete and individualized care plans for residents on anticoagulants, increasing their risk of bruising and bleeding. Despite the residents' medical conditions, their care plans lacked specific interventions to address these risks. Staff interviews revealed an expectation for care plans to reflect residents' needs, but this was not consistently implemented.
The facility failed to discard outdated food, properly label and date food items, and maintain proper infection control practices during food preparation. Additionally, kitchen equipment was found to be heavily soiled, indicating a lack of regular cleaning and sanitization.
The facility failed to reconcile petty cash monthly and did not maintain sufficient funds in the resident trust account for three months. Discrepancies were found between reported ending balances and actual bank statement balances, with funds transferred to the corporate account, resulting in insufficient funds to cover residents' balances.
The facility failed to check the federal indicator for abuse, neglect, or misappropriation of resident property through the state Nurse Aide (NA) registry prior to hiring new employees. The policy did not direct staff to check the NA registry for all employees, only for CNAs. This oversight was identified in the files of a Dietary Aide, an RN, and an LPN, none of which contained documentation of the NA registry check. The Administrator confirmed this gap in the hiring process.
The facility failed to ensure that 10 randomly selected CNAs received the required annual 12-hour resident care training. A review showed that none of the CNAs met the required training hours, with some receiving as little as 34 minutes to 8 hours of education. The facility lacked a tracking system for in-service education, and the previous MDS coordinator responsible for education had left two weeks prior. The Administrator acknowledged the issue and stated that three nurse managers would now be responsible for tracking education hours.
The facility failed to follow infection control standards by allowing a resident's urinary catheter tubing to drag on the floor and not disinfecting a mechanical lift between uses for two residents. Despite staff presence, no one intervened to correct these issues, leading to deficiencies in infection prevention and control.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. Two LPNs did not follow the manufacturer's recommendation to prime an insulin pen with 2 units before administering the prescribed dose to a resident with diabetes and other conditions.
Failure to Follow Wound Care and Compression Stocking Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and compression therapy as ordered for two residents with lower extremity wounds. One cognitively intact resident with heart failure, hip fracture, diabetes, and kidney disease had non‑pressure wounds on the left anterior and lateral leg, caused by being struck with something. The resident’s care plan did not address wound care, despite active wound treatment orders specifying cleansing with wound cleanser or normal saline, application of skin prep, xeroform gauze, collagen powder, gauze, and Kerlix wrap secured with tape. Documentation showed wound treatments were not completed on certain ordered days. Observations revealed dressings dated several days earlier that were saturated with serous drainage, with surrounding skin macerated, and the resident reported having to change a wet sock due to drainage. During wound care observations, an LPN removed a saturated dressing that had been in place for multiple days and applied only a Mepilex dressing, omitting the ordered skin prep, xeroform, collagen powder, gauze, and Kerlix. The LPN also did not apply the resident’s ordered XXL knee‑high compression stockings, despite an active order for application in the morning and removal in the evening. On multiple subsequent observations, the resident continued to be without compression stockings, and the left leg dressing remained saturated with serous drainage and dated several days prior. The ADON later performed the wound treatment and stated the facility did not have collagen powder available, and she completed the dressing change without it. Facility leadership, including the ADON and DON, stated that nurses were responsible for completing wound treatments as ordered, ordering needed supplies, and accurately documenting treatment completion. A second resident, admitted with diagnoses including CHF, pneumonia, glaucoma, and diabetes, had no baseline care plan to direct staff on care needs. An order was in place to cleanse a skin tear on the left lower leg with normal saline, apply xeroform, and a dry dressing daily and PRN. From the date the order was initiated through several subsequent days, staff did not document completion of the ordered treatment. The resident reported having a wound on the left leg/ankle, and a CNA reported that the wound occurred when the resident’s leg became caught during a transfer with a PT. Observation later showed the dressing on the left leg still dated from the initial treatment date, indicating that ordered daily and PRN wound care had not been performed or documented during that period. The Regional Nurse Consultant confirmed that nurses were responsible for documenting completion of wound treatments and following physician orders.
Failure to Maintain Personal Property Inventories and Provide Accurate Admission and Deposit Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain and update residents’ personal belongings inventories and to follow its grievance and missing property policy, as well as failures related to admission information and financial agreements. The facility’s policy dated 7/1/25 stated that residents and representatives have the right to report missing items, that staff may resolve grievances immediately or follow the grievance procedure if unable to do so, and that supervisory personnel are responsible for notifying residents and representatives of the outcome of missing property investigations. For one cognitively intact resident admitted on 6/3/25 with diagnoses including arthritis and spinal stenosis, there was no inventory of personal belongings sheet in the medical record despite observation of multiple personal items in the room. This resident reported missing specific clothing items, stated they had informed multiple staff members, and reported that no one followed up and that they had never been provided an inventory sheet at admission or afterward. Another cognitively intact resident admitted on 4/27/25 with diagnoses including heart failure, hip fracture, diabetes, and kidney disease also had no inventory sheet in the record, despite having numerous clothing items in the room, and reported multiple tops missing after being sent to laundry, stating they had never completed an inventory of personal belongings. Staff interviews confirmed that the facility’s process required inventory sheets to be completed on admission and updated when new items were brought in, with forms to be scanned into the medical record. A CMT stated that paper inventory sheets were available on each hall and should be completed and updated, and the Laundry Supervisor stated that an inventory sheet should exist for every resident and be located either in the medical record or in the resident’s room. The Laundry Supervisor reported not having seen inventory sheets for the two residents with missing clothing and being unable to locate their missing items. The Administrator and DON stated they expected staff to complete inventory sheets on admission and update them when new items arrived, and that staff should attempt to locate missing clothing and initiate an investigation if items were not found. Additional deficiencies involved admission information and financial agreements. One resident admitted on 1/5/26 with diagnoses including anxiety, diabetes, and open angle glaucoma did not have a baseline care plan in the record and reported not receiving a welcome/admission packet on admission; the admission packet on file was signed by the resident on 1/23/26, indicating it was not provided on the day of admission as expected by the Administrator. The facility’s prior admission agreement under the previous management company required a $6,000 interest-free security deposit, refundable within 45 days after discharge, and described how it would be treated for Medicaid and room-and-board charges. The current admission agreement under new management did not address the prior contract or deposits made under it. For a resident with severe cognitive impairment and multiple diagnoses including hypertension, non-Alzheimer’s dementia, and asthma, documentation from the family showed a $6,000 deposit paid at application along with room and board charges, and progress notes documented the resident’s transfer and discharge; however, invoices reviewed later showed no documentation of a refund of the $6,000 deposit. Interviews with the Regional Nurse Consultant and Administrator revealed unawareness of the prior deposit requirement, lack of documentation addressing previous deposits in the new agreement, and that funds related to deposits were not turned over during the ownership change, while the facility was still operating under the previous management company and honoring the original contract.
Failure to Pay Vendors and Maintain Adequate Supplies and Staffing for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured timely payment to key vendors and adequate procurement of supplies and services necessary for resident care. Staff interviews revealed that after a change in ownership, the facility experienced significant budget and payment issues, resulting in limited supplies such as wipes, towels, plates, gloves, and incontinence products. Central Supply staff reported that prior to the ownership change there were no supply problems, but afterward corporate imposed strict limits on quantities, downgraded product quality, and removed departmental budgets. Staff described gloves that ripped when donned and a switch from higher-quality briefs to lower-quality ones that did not contain urine effectively, with residents complaining about the briefs and staff reporting increased odors and residents being soiled. Housekeeping staff reported that the facility stopped purchasing the usual floor-cleaning chemicals and that they were using an all-purpose cleaner instead, with uncertainty about correct dilution and the last bottle nearly gone. The facility also failed to ensure timely payment to multiple critical vendors, including food suppliers, a dietician, staffing agencies, oxygen suppliers, pest control, and other service providers, placing residents at risk for interruption of services and inadequate care as stated in the report. The dietary department reported that the dish machine had been without soap and rinse chemicals for over a month, leading staff to wash dishes by hand and serve meals on Styrofoam plates and foam cups instead of regular dishware, despite resident council requests for regular plates and bowls. The Dietary Manager stated that corporate controlled ordering, frequently pushed back on quantities, and substituted cheaper or different food items than those ordered, including lower-quality ground beef and reduced quantities of produce such as bananas and grapes. The Registered Dietician reported difficulty communicating with corporate, uncertainty about the food-ordering staff’s food service experience, and that he or she had not been paid for services since the new ownership took over. Vendor records and interviews confirmed large unpaid balances to primary food vendors and other suppliers over several months with no payments made under the new management. In addition, the facility’s financial and administrative failures extended to payroll and contracted services, affecting staffing and resident care. CNAs and LPNs reported bounced paychecks, incorrect pay rates, missing hours, and unresolved payroll discrepancies, with explanations referencing time clock issues and processing from an out-of-state corporate office. A staffing agency representative reported that after ownership changed, the facility used agency staff without making any payments on multiple invoices totaling approximately $179,000, leading the agency to stop providing staff. The Plant Operations Manager and other staff reported cuts to housekeeping and maintenance staff, unpaid pest control and snow removal vendors, and multiple vendors not being paid. A beautician reported not being fully paid and receiving no assistance from the facility in contacting private-pay residents’ families for payment. An oxygen vendor, an additional food vendor, and a pest control company each confirmed that no payments had been made since before the new management took over, with balances significantly past due. The report notes that the Department of Health and Senior Services attempted to contact the corporate business office manager without returned calls, while the facility census was 91 and the deficient practice was described as having the potential to affect all residents by placing them at risk for interruption of services and inadequate care. Staff also described how these financial and operational issues contributed to staffing instability and workload problems. CNAs and LPNs reported frequent short staffing, difficulty obtaining agency staff, and situations where nurses were unsure when they would be relieved, with some working extended hours such as 23 hours on a shift. The DON was reported to be working the floor extensively, contributing to burnout, and multiple nurses reportedly left due to uncertainty about relief and staffing. The Plant Operations Manager stated that staffing and supplies were an issue and that he was pulled in different directions, including filling in for housekeeping, while the transition in ownership had been hard on residents and families. The Administrator acknowledged that there had been multiple Administrators and DONs since the ownership change, that regulatory duties were not handed off between Administrators, and that agency staffing was used to meet minimum staffing requirements, while also indicating that a system for continuity of care was still being developed. These combined actions and inactions in financial management, vendor payment, supply procurement, and staffing administration led to the cited deficiency for failure to administer the facility in a manner that enabled effective and efficient use of resources to meet residents’ needs.
Incomplete Facility-Wide Assessment and Related Care Resource Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The written Facility Assessment, last updated on 12/18/25, included basic operational data such as licensed bed count, average daily census, and average admissions and discharges by shift, but left all sections for monthly average assistance with activities of daily living (ADLs) blank. Specifically, no data were recorded for residents’ needs in bed mobility (sit to lying), mobility (sit to stand), bathing, transfers, eating, toileting, or other care, and there were no entries for levels of assistance such as set up, supervision/partial/moderate assistance, or dependent/max assistance. The assessment also contained only general narrative descriptions of how staff assignments are determined and how the infection prevention and control program is evaluated, without tying these to quantified resident care needs. During the survey, additional problems were identified that related to staffing, training, and infection control, which were not reflected in or supported by the incomplete facility assessment. These included the absence of required 12-hour CNA competencies in abuse/neglect and/or dementia care for all sampled CNAs employed more than one year, insufficient nursing staff to meet resident needs as evidenced by staff interviews and reports of missed treatments and missed ADL care, and the lack of a restorative program or speech therapy. Infection control issues were also found, including missing tuberculosis testing for all sampled residents, residents on enhanced barrier precautions without appropriate signage or PPE supplies, and housekeeping staff not using an EPA-registered hospital disinfectant for floor cleaning. In an interview, the Administrator stated an expectation that the facility assessment be fully completed with total numbers of residents requiring assistance and acknowledged responsibility for ensuring the assessment’s completion.
Failure to Implement EBP, Maintain Aseptic Care Practices, Disinfect Equipment, and Complete TB Screening
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies involving failure to implement Enhanced Barrier Precautions (EBP), improper perineal care technique, inadequate disinfection of shared equipment, and lack of required tuberculosis (TB) screening for residents and staff. Several residents with indwelling devices or open wounds did not have EBP signage or personal protective equipment (PPE) available, and staff did not use gowns during high-contact care activities as required by facility policy and CDC/CMS guidance. For example, a resident with a urinary catheter had no EBP order, no EBP signage, and no PPE available; CNAs performed incontinence and catheter care wearing only gloves, then used the same contaminated gloves to apply a clean brief, adjust bedding, and touch privacy curtains. Another resident with left leg wounds requiring dressing changes had saturated dressings and ongoing wound care performed by an LPN and the ADON without gowns, and without EBP signage or PPE supplies in or outside the room, despite the ADON acknowledging the resident was on EBP and that gowns were not available in the facility. Additional residents with indwelling urinary catheters and nephrostomy tubes also lacked EBP implementation. One cognitively intact resident with an indwelling catheter had no EBP orders and no EBP signage; a CNA entered the room, donned only gloves, and performed perineal care and catheter manipulation while leaning against the resident, without wearing a gown. Another resident with nephrostomy tubes and daily dressing changes had an EBP order, but repeated observations showed no EBP signage and no PPE at or near the room. A staff member entered, donned gloves, and changed the nephrostomy dressings without an isolation gown. A resident with pressure ulcers and a wound care order also had no EBP signage or PPE available over several days. Staff interviews revealed inconsistent understanding of EBP, with one LPN stating they were not exactly sure which residents required EBP and a CNA reporting that isolation gowns had not been seen for weeks. Surveyors also observed improper perineal care and hand hygiene practices. For one severely cognitively impaired resident, an LPN removed a soiled brief, cleaned the perineal area, then with the same gloved hands applied a clean brief, assisted the resident to dress, transferred the resident to a wheelchair, and propelled the resident to the dining room, without changing gloves or performing hand hygiene. Another resident with a catheter had perineal care performed without PPE, and catheter care was not completed after stool was cleaned from the rectal area; the CNA later stated they "guessed" they should clean the catheter and genitals. The facility’s own incontinent care policy required hand hygiene, glove changes, and use of clean surfaces of cloths for each wipe, which were not followed in these observations. The survey further documented failure to disinfect shared equipment and to complete required TB screening. A Hoyer lift was used to transfer one resident from bed to wheelchair and then immediately used to transfer another resident for weighing and back to bed, without any cleaning or sanitizing between residents. Staff, including an LPN, CNA, and the DON, acknowledged that the lift should have been wiped down between residents. Review of medical records for multiple newly admitted residents showed no documentation of two-step TB testing or TB screening, despite facility policy requiring TB screening at or before admission. Similarly, review of employee files for numerous newly hired staff showed no documentation of TB tests or chest x-rays, contrary to the facility’s Employee Tuberculosis Test policy. Environmental cleaning practices also failed to meet facility policy requiring use of an EPA-registered hospital disinfectant. Housekeeping staff reported that the facility had stopped purchasing the previous disinfectant product and were instead using Medorra Limpreza All Purpose Cleaner Lavender scent for floors, measuring it by eye into mop buckets without clear dilution instructions. The product container lacked an EPA registration number, and checks of EPA resources and the manufacturer’s website did not verify it as an EPA-registered or hospital-grade disinfectant. Housekeepers and other staff described supply limitations and lack of a Housekeeping Director, and the Regional Nurse Consultant confirmed there was no training on how much floor chemical to use, while the Administrator stated he expected housekeeping to use appropriate supplies and know correct chemical amounts.
Failure to Maintain an Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The written Antibiotic Stewardship policy, dated 7/1/25, stated that the facility would implement an antibiotic stewardship program as part of its overall infection prevention and control program, with the purpose of optimizing treatment of infections and reducing adverse events associated with antibiotic use. The policy identified the Medical Director, DON, IPC Nurse, and Consultant Pharmacist as leaders of the program, with support from the Administrator and governing officials. However, during an interview, the Administrator reported that the antibiotic stewardship program had not been updated since March 2025, that the IPC Nurse had recently quit, and that the facility had only just restarted the program on 1/22/26, despite the Administrator’s expectation that the program should have been in place for the facility’s census of 91 residents. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report, and no resident-specific antibiotic use data or monitoring activities were documented. The deficiency is based on the lack of an active, updated antibiotic stewardship program and the absence of established antibiotic use protocols and a monitoring system as required by the facility’s own policy.
Failure to Offer and Document COVID-19 Vaccination for Multiple Residents
Penalty
Summary
The facility failed to follow its COVID-19 vaccination policy by not offering, educating about, or documenting COVID-19 vaccination for five reviewed residents. The written policy dated 7/1/25 required that COVID-19 vaccinations be offered to all residents unless medically contraindicated, that residents be educated in an understandable manner using CDC or FDA information about risks and benefits, that they be given an opportunity to ask questions, and that the facility maintain documentation of vaccination status, education, and refusals in the medical record. Record review for the sampled residents showed no documentation that any of them had been offered or received the COVID-19 vaccine, nor that any education or refusals had been recorded. The affected residents had multiple significant medical diagnoses. One resident had heart failure and kidney disease, another had asthma and kidney disease, another had diabetes and osteomyelitis of the foot, another had heart failure and a history of stroke, and another had stroke, dysphagia, and kidney disease. Despite these conditions, there was no documentation in any of their medical records regarding COVID-19 vaccination offers, administration, or refusals. In an interview, the Regional Nurse Consultant, who also serves as the facility’s Infection Preventionist, stated that he expected COVID-19 vaccinations to be offered on admission or upon resident request, and that all vaccinations, refusals, and related education should be documented in the medical record, which was not reflected in the reviewed records.
Failure to Ensure Dignified Care and Homelike Dining Environment
Penalty
Summary
The deficiency involves failures to honor residents’ rights to dignity, respect, and a homelike environment. Surveyors observed an LPN walking down a resident hallway with earphones in, connected to a phone with music audible from approximately six feet away, and then entering a severely cognitively impaired resident’s room and providing incontinence care, dressing, and transfer assistance while continuing to wear the earphones and play music. Another resident reported that staff were always on the phone when providing care and that earbuds could be seen in staff members’ ears. The facility’s Resident Rights policy required that residents be treated with kindness, respect, and dignity, and the employee handbook explicitly prohibited the use of cell phones and headphones/Bluetooth devices in resident care areas or while providing care. Staff and leadership interviews confirmed that cell phone and earbud use during resident care was not allowed. The deficiency also includes the facility’s failure to provide meals on reusable dishware and utensils as requested by residents, instead serving food on Styrofoam and using plastic cutlery and cups for an extended period. Resident council minutes documented residents’ requests for regular plates and bowls rather than plastic or Styrofoam, and residents later reported that they knew the dishwasher was not in use when plastic cutlery began to be used and that plastic cutlery did not feel homelike. Dietary staff reported that the dish machine had been without soap and rinse chemicals for over a month, and that the facility had not had the required chemicals for about two months. The Dietary Manager stated the dish machine worked but lacked soap and rinse because the new owners did not want to use the previous, more expensive brand and were changing vendors, resulting in dishes being washed by hand and meals being served on disposable dishware. The Administrator later stated it was not appropriate to suspend use of the dish machine due to not purchasing sanitizer and rinse and that he or she had not been aware that Styrofoam plates and cups were being used instead of reusable dishware.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms and Shower Area
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for multiple residents and in a shared shower room. For one cognitively intact resident with diagnoses including acute kidney failure, major depressive disorder, and type 2 diabetes, surveyors observed on multiple dates that the wall surrounding the windowsill was broken and crumbling, allowing outside air to enter the room, and that the ceiling tile above the window was stained yellow/orange. The resident reported feeling cold from the draft, was unable to get out of bed without assistance, and expressed a desire to have the stained ceiling tile replaced. Facility staff, including an LPN, a maintenance associate, and the Plant Operations Manager, acknowledged that the wall and window had been in this condition for at least two months, were not homelike, and should have been repaired to prevent drafts. Another resident, with severe cognitive impairment and diagnoses including traumatic brain dysfunction, dementia, and anxiety disorder, was observed via a time-stamped photograph provided by a family member lying in bed with an open window in the room, uncovered feet, and shivering. The family member reported that the resident felt cold to the touch and that a tray of food from the previous night, consisting of mashed potatoes and gravy, remained untouched and wrapped in aluminum foil. A CNA later admitted to opening the window due to odor and heat in the room, was unsure how long it remained open, and stated that the resident had been completely covered with a sheet and two blankets when the CNA left. The DON confirmed being informed of the situation by the family member and stated the window should not have been opened. The Regional Nurse Consultant/IP reported there was no policy explicitly covering a safe and homelike environment. A third resident, with chronic kidney disease, major depressive disorder, anxiety, and moderately impaired cognition, was found on several observations to have dusty floors around the bed, a white powdery substance on the floor, a large wood floorboard missing under the bed, and fall mats covered with food debris and trash. Facility staff, including an LPN, the Administrator, and the Plant Operations Manager, stated they expected resident room floors to be clean, free of debris, and with intact flooring, and the Plant Operations Manager acknowledged awareness of the missing flooring. Additionally, repeated observations of a second-floor shower room showed used briefs in trash cans without liners, toilet riser seats smeared with stool and brown matter beneath them, no toilet paper in the dispenser, puddles of clear liquid on the floor near toilets, and a strong urine odor. A housekeeper reported that shower rooms were cleaned once daily, including toilets, floors, toilet paper refills, and trash removal, while the Administrator and DON stated the shower room should be clean, odor-free, and adequately supplied.
Failure to Maintain Effective Grievance Process and Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective grievance process that honored residents’ rights to voice grievances and receive prompt resolution. The facility’s written Grievance and Missing Property policy stated that residents, representatives, and families could present grievances to any staff member, that grievances would be documented on a grievance form, reviewed by the IDT within 10 working days, and that residents and representatives would be notified of the resolution. However, a grievance filed by Resident #44, who was documented as cognitively intact on a quarterly MDS dated 1/6/26, was not investigated or resolved. The resident reported filing a grievance on 1/5/26 regarding an incident in the 200 hall shower room and stated they had not heard back from the facility and felt that no one cared. Review of the grievance book showed a grievance form dated 1/5/26 with the resident’s name and a description of the shower room incident, but the sections for investigative findings, resolution, results reported to, and completion by the due date remained blank. Additional evidence showed systemic issues with the grievance process. During a resident council meeting, all five resident council representatives reported that staff very seldom contacted residents after grievances were filed and that it took months to hear back. Observations showed no grievance forms available in the lobby or on the 200 hall, and the Admissions Coordinator stated there used to be grievance forms and locked boxes on each floor and in the lobby but did not know what happened to them. An LPN and a CNA both reported they were not familiar with the grievance process and only informed the charge nurse of resident concerns. The Social Worker, newly designated as the Grievance Official, stated she was not aware of Resident #44’s grievance, and the Administrator also reported being unaware of that grievance, despite both indicating an expectation that grievances be investigated and resolved within five days and that residents and families have free access to grievance forms and a secure submission box.
Failure to Provide Adequate ADL Care, Hygiene, and Out-of-Bed Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate activities of daily living (ADL) care, including bathing, nail care, oral hygiene, and assistance out of bed, as required by facility policy and resident needs. The facility’s ADL and oral hygiene policies required staff to assist with bathing to promote cleanliness and dignity, to provide oral care per the care plan, and to notify the DON and reschedule if showers were refused. For one resident with chronic kidney disease, major depressive disorder, anxiety, and moderately impaired cognition, there was no baseline care plan in the record. This resident was observed in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week and wanting nail trimming. Another cognitively intact resident with heart failure, hip fracture, diabetes, kidney disease, and urinary incontinence was care planned for hands-on assistance with bathing and other ADLs, but was observed in stained clothing with frizzy, messy hair and reported being supposed to receive showers twice weekly, needing assistance to shower, and desiring more frequent showers due to incontinence and odor. Shower documentation showed only three showers in January and no shower records for December. A third cognitively intact resident with muscle weakness and diabetes had no ADL care needs included in the care plan. This resident was repeatedly observed in bed with toenails on both feet approximately one-eighth of an inch long and jagged, and with a whitish-yellow substance caked on the front teeth on consecutive days. The resident reported having asked staff for help with nail trimming without receiving assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA stated that nail care should be provided after showers and that lack of staffing was the reason the resident was not being assisted with oral hygiene, and confirmed the resident required staff assistance with showers and personal hygiene. Staff interviews, including with an LPN and the DON, confirmed expectations that residents receive at least two showers or bed baths weekly, that hair be washed during showers, that nails be kept clean and trimmed, and that staff assist with oral hygiene. Another cognitively intact resident with heart disease, kidney disease, and high blood pressure, requiring substantial to maximum assistance for bed mobility and transfers, had no care plan completed. This resident was repeatedly observed in bed on the back, wearing a hospital gown, and reported wanting to get out of bed and wear clothing but being reluctant to ask because staff left the resident up in a chair too long. The resident stated not having gotten out of bed on one observed day, believed being too much work for staff due to needing a Hoyer lift, and expressed a desire to see outside the room. The Director of Therapy reported the resident had no restrictions, should be transferred with a Hoyer lift, and had a special high-back wheelchair in the room. A CNA stated the resident was offered to get out of bed but would refuse, and the DON stated the expectation that the resident get out of bed daily and as requested, with refusals to be reported to the nurse and documented in the record and care plan. These observations and interviews demonstrate failures to provide and document ADL care, including bathing, nail care, oral hygiene, and assistance out of bed, in accordance with resident needs and facility policy.
Improper Transfer Techniques and Unsafe Storage of Antiseptic Solution
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer techniques with a mechanical lift and during assisted transfers, as well as failure to safely store a topical antiseptic solution. The facility’s Total Lift Transfer policy required staff to position the lift near the receiving surface, lock bed or chair wheels, open the legs of the lift, and maintain contact with the resident to guide and steady them during transfers. Despite this, surveyors observed that during a Hoyer lift transfer for a resident with dementia, anxiety disorder, depression, and total dependence for transfers, staff did not open the legs of the lift and did not maintain physical contact or guidance while the resident was being moved from the bed. The resident’s care plan specified use of a Hoyer lift with extensive to total assistance, but there was no specific transfer order in the electronic physician order sheet. In another case, a resident with severe cognitive impairment, traumatic brain dysfunction, dementia, and dependence on staff for transfers was observed being weighed using a Hoyer lift. The resident’s care plan required a Hoyer lift with two staff members for transfers. During the observation, staff positioned the wheelchair between the legs of the lift and locked the wheelchair, but after lifting the resident, one CNA moved the Hoyer lift with the legs closed while another CNA stood beside the resident with hands barely touching the resident. In interviews, one CNA stated that he/she typically closed the legs of the Hoyer when the resident was in the air because it felt like better balance, while an LPN and the DON both stated that the legs of the Hoyer should be opened during transfers to provide a stable base and that two staff should be involved, with one guiding the resident. The facility also failed to follow its Gait Belt Transfer policy, which required use of a gait belt for residents needing one-person assist with transfers. A resident with severe cognitive impairment, dementia, heart disease, heart failure, and a need for maximum assistance with transfers was observed being transferred by an LPN from bed to wheelchair without a gait belt, despite two gait belts hanging above the bed. The LPN lifted the resident under the arms and by pulling on the resident’s pants to pivot them into the wheelchair. Staff interviews confirmed that gait belts should be used for residents requiring assistance with transfers and ambulation, and the DON stated that pulling on a resident’s pants to transfer them was not acceptable. Additionally, a cognitively impaired resident with dementia, anxiety disorder, and depression was observed multiple times with an uncapped bottle of Dakin’s 0.125% solution sitting on a television stand in the room, despite the product’s warning that it was for external use only and should not be taken internally. The solution remained open and accessible in the room even when the resident was not present, and there was no physician order for the Dakin’s solution in the electronic physician order sheet.
Insufficient Nursing, Therapy Staffing, and Orientation Leading to Unmet Basic Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a 24-hour basis to meet residents’ basic care needs, as well as insufficient therapy staffing and inadequate orientation for new and agency staff. The facility’s own Facility Assessment, updated in December 2025, lacked completed data fields for residents’ assistance needs with activities of daily living such as bed mobility, transfers, bathing, eating, and toileting, despite stating that staffing assignments were based on census, acuity, and resident preferences. Observations showed residents with unmet hygiene needs: one resident was seen in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week, attributing this to not enough staff and requesting nail care. Another resident, incontinent of urine and dependent on staff for showers, was observed in stained clothing with frizzy, messy hair and reported being scheduled for showers twice weekly but wanting more frequent showers due to odor and visitors; documentation showed only three showers in January and no shower records for December. Further observations showed another resident in bed on two separate days with toenails approximately 1/8 inch long and jagged and a whitish-yellow substance caked on the front teeth. This resident reported asking staff for nail trimming without assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA confirmed that nail care should be provided after showers and attributed the lack of oral hygiene assistance to staffing shortages, noting the resident required staff help with showers and personal hygiene. In addition to nursing care issues, review of therapy minutes from early September through late January showed no speech therapy evaluations, minutes, or services offered, and the Director of Rehab reported there was no speech therapy in place, only a recently hired PRN speech therapist, and that there had been no restorative program since their start at the facility. The DON acknowledged awareness of the lack of therapy and the absence of a restorative therapy program. Interviews with nursing staff and administration revealed systemic staffing and orientation problems. One LPN, initially an agency nurse who became a direct hire, stated being a brand-new nurse who received no orientation and was unaware of how poor staffing levels were. Another LPN reported it was their first day in the building, had never worked there as agency staff, and was working solo since early morning without training, relying on resident charts and other LPNs for questions. A third LPN described ongoing short staffing since new management took over, with only one night nurse until very recently, heavy reliance on agency staff, and critical care needs on the units such as IV medications and wound vacs. This LPN also reported that the admissions nurse did not help on the floor when short-staffed, the wound nurse had quit, the DON was working the floor extensively, and staff turnover was high. The Administrator confirmed frequent leadership changes, heavy use of agency staff, issues with RN coverage, and that regulatory duties were not handed off between administrators, while stating that agency staffing was used to meet minimum staffing requirements and that the DON was working on a system to ensure continuity of care amid frequent staff turnover.
Widespread Failure to Obtain and Administer Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered medications were obtained from the pharmacy and administered as ordered, resulting in numerous missed doses and “drug not available” occurrences for multiple residents. Facility policies required timely faxing and reordering of medications, use of the emergency kit or automatic dispensing unit for first doses, and prompt transcription and implementation of physician orders, including ensuring prompt delivery from the pharmacy. Despite these policies, staff frequently documented medications as unavailable, left blanks or holes on the MARs where doses should have been recorded, and did not consistently ensure that orders were correctly entered when the facility changed electronic medical record (EMR) systems. One resident with multiple sclerosis, repeated falls, and obstructive sleep apnea had an order for modafinil 100 mg, three tablets once daily, and Glatopa 40 mg SQ every other day. Modafinil was documented as drug not available for 20 of 22 opportunities, and Glatopa was documented as drug not available for 5 of 10 opportunities in one EMR system. After the facility switched to a second EMR, Glatopa was documented as not administered 8 of 9 opportunities, and the modafinil order was incorrectly entered as 100 mg, one tablet, instead of three tablets. A nurse’s note indicated the resident had not received modafinil since admission, and the DON later confirmed the EMR 2 order was incorrect. The pharmacist stated that only two doses of Glatopa (a one-week supply) had been dispensed and that failure to dispense or give modafinil correctly could potentially increase fall risk. Another resident with muscle weakness and diabetes had an order for tramadol 50 mg twice daily for pain, but the eMAR showed multiple missed doses over nearly two weeks, with staff documenting that tramadol was not administered because it was unavailable. The resident reported not receiving pain medication routinely. A different resident with acute kidney failure, acute respiratory failure, and muscle weakness had orders for tramadol, Bion Tears eye drops, and olopatadine eye drops; the eMAR showed repeated missed doses of all three medications over several days to weeks, with progress notes consistently stating the medications were unavailable. This resident reported not receiving eye drops and stated nurses told them the drops were not available. A resident with chronic kidney disease, major depressive disorder, and anxiety had an order for midodrine 2.5 mg twice daily and for sodium chloride 0.9% IV infusions twice weekly. After the facility switched EMR systems, there was no physician order or administration documentation for midodrine in the new EMR, and two bags of sodium chloride labeled for the resident were observed sitting on top of the medication room refrigerator, with blank documentation for certain infusion dates. A hospital nurse reported that when this resident arrived at the hospital, their blood pressure was very low and remained low overnight. The DON later stated the midodrine order had not been transferred correctly into the new EMR and that the resident should have received the sodium chloride infusions. Another resident with chronic pain, diabetes, anxiety, high blood pressure, and a history of healed physical injury had an order for atenolol 50 mg daily, which was documented as not administered for all available opportunities. The same resident had an order for Augmentin three times daily for a urinary tract infection, with multiple doses over several days documented as not administered. The resident stated they had never received atenolol since it was ordered and had not received the antibiotic, and staff told them the antibiotic was on order. A further resident with coronary artery disease, heart failure, diabetes, high cholesterol, anemia, peripheral vascular disease, hypothyroidism, major depressive disorder, and chronic kidney disease had multiple cardiac, anticoagulant, thyroid, and blood pressure medications ordered, including atorvastatin, levothyroxine, metoprolol, midodrine, spironolactone, Eliquis, clopidogrel, and amiodarone. The eMAR showed extensive missed doses for each of these medications, with some documented as medication not available and others simply not given, and only one progress note indicating a call to the pharmacy about spironolactone. Staff interviews revealed systemic issues contributing to the missed medications. A certified medication technician stated that the facility had recently changed to a new medication ordering system, that the system was “messed up,” and that medications were frequently not given because they had not been ordered properly; the technician also reported not receiving proper training on the new system. An LPN stated that medications should be administered per physician order and that if a medication was unavailable, the nurse should document this and call the physician or pharmacy. The DON stated that holes and blank spots on the MAR meant medications were not given, that staff should check the Pyxis and request STAT delivery if medications were out, and that if a medication was on backorder, the physician should be contacted for a substitute order. The DON also stated that staff were expected to reorder medications timely and notify pharmacy and the physician after one missed dose, rather than after multiple missed doses, which contrasted with the repeated documentation of unavailable medications and numerous missed administrations found in the records.
Failure to Ensure Accessible Call Lights and Timely Repair of Shower
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were accessible and by not repairing a shower in a timely manner. One resident with severe cognitive impairment, Alzheimer’s disease, osteoarthritis, and insomnia was care planned as being at risk for falls and encouraged to use the call light for assistance with transfers. Multiple observations over several days showed this resident seated in a recliner while the call light was wrapped around the bed rail at the top of the bed or under the pillow, consistently out of reach. The resident stated a desire to go to bed but reported the call button was not within reach. A CNA and an LPN both confirmed the resident was able to use the call button and that it should have been within reach. Another resident with severe cognitive impairment, dementia, heart disease, and heart failure was dependent on staff for personal and toilet hygiene and was care planned to have the call light kept within reach at all times due to fall risk related to impaired mobility and altered mental status. On two separate observations, this resident was lying in bed while the call light was positioned on the floor behind the headboard, not accessible to the resident. A CNA and the DON both stated that call lights were to be positioned within residents’ reach at all times, regardless of cognitive status, which was inconsistent with the observed placement of the call lights for these residents. The facility also failed to provide reasonable accommodation by not repairing a shower in the 200 hall shower room for approximately a month. A cognitively intact resident with arthritis and spinal stenosis, who did not have a bathroom in the room, reported self-propelling in a wheelchair to the 200 hall shower room to use the bathroom but was unable to shower there because it was broken. The resident stated the shower had been broken for over a month, requiring use of another shower room located further down the hall and often needing staff assistance to reach it. Observations on multiple days showed a sign posted in the 200 hall shower room stating, "Please do not use shower." The maintenance associate and maintenance director both acknowledged the shower had been broken for about a month, with the maintenance director stating he had not gotten around to fixing it, while the administrator reported being unaware of the issue.
Failure to Track and Refund Resident Security Deposit After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to implement a process to identify and return refundable resident deposits upon discharge, as required under a prior admission agreement. The previous management’s admission contract, revised on 3/22/23, required a $6,000 interest‑free security deposit to reserve a room, with the deposit to be refunded within 45 days after discharge, less applicable balances. Review of records for one resident showed an application dated 4/2/25 with a documented $6,000 deposit and additional room and board charges due at signing. However, later invoice review showed no documentation of the $6,000 deposit. The current admission agreement under new management did not address the prior $6,000 deposit requirement or how deposits made under the previous management’s contract would be handled. The resident associated with the missing deposit had severe cognitive impairment and diagnoses including HTN, non‑Alzheimer’s dementia, and asthma, and was discharged to another facility, as documented in progress notes describing coordination with the resident’s daughter and transfer by transportation with a Broda chair and Hoyer pad. Interviews revealed that the Regional Nurse Consultant was unaware of the prior contract’s $6,000 deposit and refund requirement and stated that the new management did not require such deposits, though they were still under the previous management until the change of ownership was completed and were honoring the original contract. The Administrator reported that funds were not turned over during acquisition and that all information had been requested from the previous ownership, but also stated unawareness of the specific deposit while acknowledging that the corporate Business Office Manager knew of it. These findings show that the facility lacked an effective process to track and return refundable deposits owed to discharged residents under the prior agreement.
Failure to Ensure Safe and Coordinated Discharge Planning for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and properly planned discharges in accordance with its own discharge planning policy. The policy required an IDT-driven discharge process, including a physician’s order, coordinated discharge planning by social work, therapy home assessments as needed, referrals to home health or other services, nursing education on medications and treatments, and completion and distribution of a discharge summary with documentation in the medical record. Surveyors found that these steps were not followed or documented for two residents who were discharged. For one resident with anxiety, diabetes, and open-angle glaucoma, there was no baseline care plan in the record and the resident reported being “kicked out.” The social worker reportedly told the resident it was not in her job description to find a new placement and stated she could not help residents file appeals. The resident received a NOMNC with a set discharge date and reported being unable to fully participate in therapy due to COVID and a strained neck. Therapy staff, including the OT and the Director of PT/OT, described the resident as non-ambulatory, needing moderate assistance with showering, assistance with toileting and dressing, and having very weak legs. The Director of PT/OT stated she did not feel it was safe for the resident to return home due to the number of stairs and the resident’s limited ability to manage steps, yet the resident was discharged home after arranging their own transportation, with no indication of a coordinated safe discharge plan. For another resident who was cognitively intact and had multiple diagnoses including hypertension, peripheral vascular disease, diabetes, hyperlipidemia, depression, and asthma, the record contained no physician order for discharge. The only documentation was a progress note stating the resident was discharged home with medications and that nurse management was aware. There was no documentation of discharge planning, referrals, outside resources, or a discharge summary in the medical record. In an interview, the DON stated that the expectation was for the social worker to assist with discharge planning and for all services to be documented, including a discharge summary, but this was not done for the residents reviewed.
Failure to Provide Ordered Ostomy Care and Staff Awareness for Resident With Ileostomy
Penalty
Summary
The deficiency involves the facility’s failure to provide ostomy care and obtain physician orders for a resident with an ileostomy, contrary to its own policy requiring licensed nurses to provide ostomy care under physician orders specifying type of ostomy, frequency of pouch changes, and equipment. The resident’s admission MDS documented moderately impaired cognition, diagnoses including Crohn’s disease, ileostomy status, chronic kidney disease, major depressive disorder, and anxiety, and the presence of an ostomy appliance. However, review of the physician order summary showed no orders for ostomy care, and the medical record contained no baseline or comprehensive care plan addressing ostomy care needs. During interview, the resident reported feeling shaky and unwell and was unable to answer specific questions about medical needs. A family member reported that family had been coming in to assist with ostomy care because staff were not helping the resident empty the ostomy bag, resulting in the resident waiting for family assistance, and stated that concerns had been reported to a DON without any response. Staff interviews further demonstrated lack of awareness and direction regarding the resident’s ostomy. One LPN described responding to a loud noise from the resident’s room and finding the resident on the floor after an unwitnessed fall, with feces covering the floor and the resident holding the ostomy bag to prevent further leakage; the resident stated they had been trying to walk to the bathroom to empty the bag. The resident was sent to the hospital for shoulder pain and altered cognitive status. That LPN, as well as another LPN, both stated they were unaware the resident had an ostomy bag and confirmed there were no physician orders for ostomy care or information on whether the resident could manage the ostomy independently. The DON later stated an expectation that staff assist with ostomy care, be informed of the ostomy’s presence, have a care plan with ostomy interventions, have physician orders for ostomy care, and that concerns reported by family be addressed, underscoring that these expectations were not met in this case.
Improper Medication Storage, Labeling, and Temperature Control on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were stored securely, properly labeled, and maintained at appropriate temperatures in accordance with facility policy and professional standards. On one medication cart, surveyors observed personal items including two individually wrapped cupcakes, an earring, and a personal fan stored on the cart. In the same area’s medication room, a mini refrigerator containing a variety of medications for multiple residents was found unplugged, with the temperature gauge reading 65°F and a high temperature alarm displayed. Temperature readings taken over several minutes showed the refrigerator temperature remained outside the facility’s required 36°F to 46°F range, and the temperature log showed no documented checks for several consecutive days. On another hall’s nurse cart, surveyors observed non-medication items such as dry erase markers in the top drawer and multiple medications that were not properly labeled. These included insulin pens without open dates and with resident names handwritten only on the caps, and topical creams (Boudreaux’s Butt Paste and Desitin) without open dates or resident names. On the corresponding CMT cart, a half white circular pill identified as trazodone 50 mg remained in a pill cutter, indicating a loose, unidentified dose not stored in its original packaging. Staff interviews revealed that night shift staff were responsible for checking refrigerator temperatures, but the LPN on duty did not confirm that the refrigerator had been checked and was unfamiliar with the facility’s policy. On the Med A Hall nurse cart, surveyors found 13 insulin pens with only handwritten names and no patient labels, as well as topical medications such as betamethasone valerate ointment and Aspercreme without open dates. A biohazard bag on the cart contained 24 expired urine tubes and urine culture tubes, and a plastic bag labeled for refrigeration contained two prefilled syringes of glatopa 40 mg/mL that were not in a refrigerator. On the Med A Hall CMT cart, a blister pack of loperamide 2 mg and a blister pack of cetirizine with four remaining pills were present without patient labels or open dates, and a loose oval white pill was also observed. During interview, the DON confirmed that insulin pens should have proper patient labels and that resident names should not be handwritten on caps, and stated that when a resident is discharged, the nurse is primarily responsible for removing and destroying medications no longer in use.
Failure to Provide Ordered Therapy, Offer ST, and Maintain a Restorative Program
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered, failure to offer speech therapy (ST) over several months, and failure to maintain an active restorative program in accordance with resident needs. Facility policy required that therapy services be provided under physician orders, coordinated with the interdisciplinary team, and accurately documented in the medical record, with periodic evaluation of effectiveness. Review of therapy minutes showed no ST evaluations or services offered during the review period, and interviews confirmed there was no restorative nursing program in place following a change in ownership and therapy staffing transitions. One resident, identified as having moderate cognitive impairment and multiple diagnoses including heart failure, coronary artery disease, hypertension, MDRO, anxiety, and depression, required extensive assistance with mobility and transfers and used a wheelchair/scooter. The resident’s MDS dated 10/24/25 showed no therapy minutes and no days in a restorative nursing program, despite physician orders for PT/OT/ST to evaluate and treat for transfer status, functional decline, and confusion. Orders for PT/OT/ST were initiated and then discontinued on two separate occasions, and the resident’s care plan did not document the outside therapy services the resident was receiving. Progress notes documented that the resident left the facility for outside therapy appointments and that the physician noted the resident was receiving outside PT five times per week, but this outside therapy was not reflected in the care plan or therapy documentation as required by facility policy. Interviews with the resident and family member revealed that the resident did not receive consistent PT or ST in the facility and had a three‑month period without therapy after an ownership change and staff turnover. The family arranged for the resident to attend an outside day program providing PT five days per week, with the family providing transportation after the facility stated it could not provide daily transport. The Director of Rehab stated the resident had not received in‑house therapy since the director’s start date, that there was no ST available during the period in question, and that there was no restorative program in place. The DON acknowledged awareness that the resident received outside therapy and stated expectations that such services should be scheduled, coordinated, documented, and care planned, but confirmed there was no restorative therapy program operating at the facility during this time. Additional staff interviews corroborated that there was a gap in PT/OT services during the transition to new ownership and that the restorative aides were removed without replacement, leaving the facility without a restorative program. The Plant Operations Manager reported that therapy under the prior contract became “light” during the transition and that nursing management handled therapy after the therapy company left. The Dietary Manager and Director of Rehab confirmed that ST had not been provided during the review period, with only a plan for telehealth ST and a new ST hire pending. Collectively, these findings show that the facility did not provide therapy services as ordered, did not offer ST for an extended period, and did not maintain an active restorative program, and failed to update the medical record and care plan to reflect and coordinate the resident’s outside therapy services.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
A resident with a history of severe pain due to neuropathy, recent orthopedic and heel surgery, and multiple pressure ulcers did not receive pain medication as ordered by the physician. Upon admission, the resident was assessed as having frequent, severe pain, and had orders for both acetaminophen and oxycodone to be administered as needed for pain management. Despite these orders, documentation shows that the resident did not receive acetaminophen from the time of arrival through several days, and there were inconsistencies in the administration of oxycodone, with gaps in documentation and missed doses. On one occasion, the resident reported pain at a level of 10/10, which was described as their baseline, and repeatedly requested pain medication throughout the night. Certified Nurse Aides (CNAs) observed and reported the resident crying, yelling, and expressing severe pain multiple times to the agency charge nurse. The agency nurse did not administer the ordered pain medication, citing lack of access to the automated drug dispensing machine (Pixus), and did not notify facility leadership or the physician about the inability to provide the medication. The nurse also refused to provide care, stating their shift had ended, and left the facility before the replacement nurse arrived, leaving the resident without pain relief for an extended period. Interviews with staff confirmed that agency nurses did not have access to the Pixus and were expected to request assistance from facility nurses to obtain medications. However, this process failed, resulting in the resident not receiving pain medication as ordered. The DON and Administrator were not made aware of the resident's pain or the medication access issue until the following morning, and the resident's physician was not notified of the problem. The facility's pain management policy required systematic recognition, evaluation, and treatment of pain, but these procedures were not followed, leading to the resident experiencing unmanaged severe pain.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Deficient Care Plans for Residents on Anticoagulants
Penalty
Summary
The facility failed to ensure that residents receiving anticoagulant treatment had complete, accurate, and individualized care plans to address their increased risk of bruising and bleeding. This deficiency was identified for three residents who were on high-risk drug classes, including anticoagulants and antiplatelets. Despite the residents' medical conditions, such as atrial fibrillation, coronary artery disease, and history of pulmonary embolus, their care plans lacked specific interventions to mitigate the risk of bleeding and bruising. Observations during the survey showed no visible bruises on the residents, but the care plans did not reflect necessary preventive measures. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that there was an expectation for all residents to have care plans that reflect their needs. However, the LPN admitted to not always creating care plan interventions for residents on medications that increase the risk of bruising or bleeding. The Director of Nursing and the Administrator both expressed that they expected the nursing department to adhere to the facility's care plan policy, which was not followed in these cases.
Food Storage and Infection Control Deficiencies
Penalty
Summary
The facility failed to discard outdated food and properly label, date, and cover food items in their storage areas. Observations revealed multiple instances of expired food items, including cans of potato salad, soup, V8 drink mix, and cherry pie filling. Additionally, several containers in the cooler and freezer were found without dates, and some food items were exposed to air due to improper storage. The Dietary Manager acknowledged that all staff were responsible for ensuring food was properly labeled, dated, and expired items were discarded, but these practices were not followed consistently, leading to potential risks for residents consuming food from the facility kitchen. Furthermore, improper infection control practices were observed during food preparation. A cook was seen using gloves to handle pureed vegetables and then scraping the mixture into plates with their hands, followed by rinsing the gloves instead of changing them. The cook also handled fish with the same gloves before discarding them. The Dietary Manager confirmed that proper infection control practices, including glove changes and handwashing, were expected but not adhered to. Additionally, the kitchen equipment, including the stove and ovens, was found to be heavily soiled with caked-on stains and blackened matter, indicating a lack of regular cleaning and sanitization. The Dietary Manager admitted that the equipment was not cleaned as required, which was her and her assistant's responsibility.
Failure to Reconcile Petty Cash and Maintain Sufficient Resident Trust Funds
Penalty
Summary
The facility failed to reconcile the petty cash on a monthly basis and did not maintain sufficient funds in the resident trust account to cover all residents with a trust account for three months. The facility held funds for five residents, and the census was 81 with 38 residents in certified beds. The monthly accounts from April 2023 through March 2024 lacked documentation of the ending balances for petty cash. The Accounting Coordinator confirmed that the petty cash was not included in the reconciliation sheet because it was considered separate from the bank funds. Additionally, the monthly balance reports showed discrepancies between the reported ending balances and the actual bank statement balances, with amounts transferred from the resident trust account to the facility's corporate account, resulting in insufficient funds to cover the residents' balances if they wanted to close their accounts. During interviews, the Accounting Coordinator and the Administrator provided conflicting information about the source of the petty cash funds and the reconciliation process. The Administrator expected the resident trust to be accurately reconciled every month and believed the petty cash was company-funded, but would need to verify. The Accounting Coordinator stated that if there was not enough money in the account, they would provide the resident with cash. The facility's failure to accurately reconcile the resident trust account and maintain sufficient funds led to the deficiency identified in the report.
Failure to Check NA Registry for All New Hires
Penalty
Summary
The facility failed to check the federal indicator for abuse, neglect, or misappropriation of resident property through the state Nurse Aide (NA) registry prior to hiring new employees. Specifically, the facility's policy did not direct staff to check the NA registry for all employees, only for Certified Nursing Assistants (CNAs). This oversight was identified in the employee files of a Dietary Aide, a Registered Nurse (RN), and a Licensed Practical Nurse (LPN), none of which contained documentation of the NA registry federal indicator check. The facility's Background Screening Investigation policy mandates employment background checks, reference checks, and criminal conviction checks, but it did not include a requirement to check the NA registry for all staff members, leading to this deficiency. The Administrator confirmed that the NA registry was only checked for CNAs, contrary to what is expected for all new hires. The deficiency was identified during a review of employee files and an interview with the Administrator. The employee files reviewed included those of a Dietary Aide hired on 8/18/23, an RN hired on 5/2/23, and an LPN hired on 1/30/24. None of these files had documentation of the NA registry federal indicator check. The Administrator acknowledged this gap in the hiring process, confirming that the NA registry was only checked for CNAs, which is not in compliance with the expected procedure for all new hires. The facility's policy failed to ensure comprehensive background checks, including the NA registry check for all staff, leading to this deficiency in their hiring practices.
Failure to Track CNA Training Hours
Penalty
Summary
The facility failed to have a tracking system to ensure that 10 of 10 randomly selected Certified Nurse Aides (CNAs) received the required annual 12-hour resident care training, tracked and calculated by hire date. The census was 81 with 38 residents in certified beds. The facility assessment indicated various training and competencies that staff should receive, including abuse prevention, dementia care, and medication administration. However, a review of individual in-service records showed that none of the CNAs met the required 12 hours of training, with some receiving as little as 34 minutes to 8 hours of in-service education. The facility's in-service sign-in sheets lacked documentation of the amount of time for each in-service or education event, and there was no tracking of which CNAs attended these sessions or the dates of the education events. During an interview, the Administrator revealed that the previous Minimum Data Set (MDS) coordinator, who was responsible for education, had left two weeks prior, and the facility was currently looking for a new educator. The Administrator acknowledged the lack of a tracking system and stated that three nurse managers were now responsible for tracking in-service education. Moving forward, the education would be tracked through payroll, with the Administrator initiating it and nurse managers tracking the clinical information. Despite these plans, the facility had no current system in place to ensure CNAs received the required training hours, leading to the deficiency identified by the surveyors.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control for three residents. Specifically, the facility did not ensure that the tubing for an indwelling urinary catheter did not drag on the floor for one resident. The resident, who had diagnoses including kidney disease stage three and chronic kidney disease, was observed multiple times with the urinary catheter tubing and drainage bag dragging on the floor while self-propelling in a wheelchair. Despite passing by several staff members, no one assisted the resident in repositioning the catheter tubing to prevent it from dragging on the floor. The facility's policy did not provide specific instructions on the proper positioning of the catheter tubing, contributing to this oversight. Additionally, the facility failed to clean shared medical equipment between resident use. Two residents were observed being transferred with a mechanical lift that was not disinfected between uses. The staff retrieved the Hoyer lift from the hall, used it to transfer one resident, and then immediately used the same lift to transfer another resident without sanitizing it in between. This action was contrary to the facility's policy, which required cleaning shared equipment with an antiseptic wipe between uses to prevent the transmission of pathogens. During an interview, the Director of Nursing (DON) confirmed that the facility's policy mandates proper infection control practices, including keeping urinary catheter tubing off the floor and cleaning shared medical equipment between uses. However, these practices were not followed, leading to deficiencies in infection prevention and control for the residents involved.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 7.14% error rate. Out of 28 medication administration opportunities observed, 2 errors occurred involving a resident with diagnoses including epilepsy, type 2 diabetes with polyneuropathy, and chronic kidney disease. The errors were related to the improper priming of an insulin pen before administering the prescribed dose of Lantus insulin. Specifically, the Licensed Practical Nurses (LPNs) involved did not follow the manufacturer's recommendation to prime the pen with 2 units of insulin before administering the resident's dose. On two separate occasions, LPNs failed to prime the insulin pen correctly. One LPN primed the pen with only 1 unit instead of the recommended 2 units, while another LPN did not prime the pen at all before administering the insulin. The Director of Nursing (DON) confirmed during an interview that the insulin pens should be primed with 2 units as per the manufacturer's guidelines. This failure to follow proper procedures led to the identified medication errors.
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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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