Heritage Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4401 North Hanley Road, Saint Louis, Missouri 63134
- CMS Provider Number
- 265534
- Inspections on file
- 40
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 31 (1 serious)
Citation history
Health deficiencies cited at Heritage Care Center during CMS and state inspections, most recent first.
The facility discontinued services with one attending physician and reassigned multiple residents to new physicians without honoring their right to choose their own provider. Two residents with no cognitive impairment and histories including stroke, cancer, diabetes, high blood pressure, and depression reported they were told their physician would no longer be available and that they would be assigned a new one, without being asked for their preference or given an opportunity to remain with their original physician. One resident, who stated he/she was his/her own guardian and POA, was documented as having a guardian notified of the change, despite no guardian being recorded in the chart. The Administrator and DON reported they followed a corporate directive to notify residents of the change, did not send written notices, and did not ask residents if they wanted to change physicians, despite a policy stating residents have the right to choose their attending physician and be fully informed in advance of changes in care.
A resident with schizoaffective disorder, bipolar type, impaired judgment, and a documented history of elopement from prior secure facilities was care planned for intensive monitoring but was housed in a room adjacent to an exit door and not reassessed for elopement risk after the guardian requested transfer to a secure unit. On the day of the incident, staff noted the resident missed smoking and dinner, a door alarm sounded and was silenced by a CNA, and an LPN relied on another resident’s report instead of directly confirming the resident’s presence before leaving at shift change. The oncoming LPN found the resident already gone, initiated a search and code white, and later documentation and MAR entries showed missed doses of multiple psych and chronic meds with the resident marked as out of the building, revealing that the resident’s absence had gone unrecognized for several hours despite facility policies requiring elopement monitoring, intensive monitoring, and regular walking rounds.
Two cognitively intact residents with psychotic disorders and schizophrenia became involved in an altercation in which one resident pulled a screwdriver or similar object and attempted to stab the other, with witnesses reporting both verbal and physical fighting. An LPN initially documented that a screwdriver was used, then altered the note to say "object," while a CMT and one resident consistently described a screwdriver and physical contact, and police were notified. Despite facility policies requiring comprehensive incident and abuse investigations, written witness statements, and care plan revisions for resident-to-resident altercations, the facility’s investigation lacked written statements from involved staff and residents, did not include input from maintenance regarding the alleged source of the screwdriver, and failed to update either resident’s care plan or document the incident in one resident’s nursing notes.
The facility did not complete a thorough facility-wide assessment to determine necessary resources and staffing for competent resident care during daily operations and emergencies. The assessment lacked required details on staffing ratios, RN coverage, and staff competencies, and the facility was missing a full-time DON and social worker. The administrator confirmed the assessment was incomplete, with only external contact information documented.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with multiple resident rooms and shared bathrooms exhibiting unpainted drywall, exposed holes, missing cove base, dirty and sticky floors, and evidence of pests. Maintenance staff reported that repairs were delayed due to slow supply deliveries caused by budget cuts.
The facility did not maintain a full-time DON who was not also serving as a charge nurse when the census was 105, contrary to policy and regulatory requirements. During the DON's medical leave, the RN Supervisor acted as interim DON but also provided RN coverage, and there was confusion among staff about who was fulfilling the DON role. Corporate RN staff provided intermittent coverage, but the facility lacked a consistent, full-time DON not assigned as a charge nurse.
The facility did not maintain an accurate accounting system for resident trust fund accounts, failing to complete proper monthly reconciliations and resulting in discrepancies between reported and actual cash on hand. Staff interviews confirmed inconsistent practices in tracking and reconciling petty cash, and expectations for monthly reconciliation were not met.
A resident with a history of aggression and mental health diagnoses was placed in a head lock by a staff member during an altercation, following an attack on a CNA. The staff member, despite CPI training, did not use approved de-escalation or restraint techniques, resulting in a violation of the resident's right to be free from physical abuse. Staff interviews confirmed improper intervention and a lack of coordinated response during the incident.
A resident's trust funds were withdrawn and used to purchase clothing, furniture, and other items without the resident's consent or required signature. The BOM made these purchases based on staff input rather than direct resident authorization, and the resident later reported not wanting or receiving several of the items. Facility policy requiring resident permission and signatures for withdrawals was not followed.
A resident with terminal diagnoses was not enrolled in hospice services despite hospital discharge orders and care plan interventions indicating hospice care. Staff discovered the lack of hospice enrollment only after a significant decline in the resident's condition, but did not notify the physician of this discovery or document key assessment findings in the medical record. The resident expired without receiving hospice services, and required notifications and documentation were not completed as per facility policy.
A resident with severe back pain and multiple comorbidities did not receive a physician-ordered opioid pain medication due to staff failing to transcribe and process the order. Instead, the resident was intermittently given Tylenol, which was reported as ineffective. Staff interviews revealed a lack of awareness of the opioid order, and the order was never sent to the pharmacy, resulting in inadequate pain management.
A deficiency was cited for not ensuring an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The issue remains uncorrected, with references to previous similar citations.
A resident with a history of severe mental health conditions and repeated self-harm incidents was left unsupervised when the assigned 1:1 staff was reassigned due to short staffing. During this unsupervised period, the resident broke a window and used the glass to inflict deep cuts, requiring medical intervention. Facility policy and the resident's care plan required continuous 1:1 supervision, but this was not maintained, leading to the incident.
A cognitively intact resident with a history of sex offender status was transferred from a sister facility and placed on a locked unit without being informed, consulted, or allowed to participate in their care planning. The resident expressed distress and confusion about the transfer and placement, and facility staff confirmed that the process did not include proper communication, assessment, or documentation. The placement decision was made solely based on the resident's sex offender status, without evidence of recent behavioral issues or individualized risk assessment.
A cognitively intact resident was placed on a secured unit solely because of sex offender status, without clinical justification or assessment, and was not informed or given options regarding the transfer. Facility staff confirmed the placement was based on policy rather than individualized evaluation, and documentation lacked evidence of risk assessment or behavioral issues.
The facility did not provide reliable WiFi access for residents, resulting in multiple individuals being unable to use electronic communications such as email, video calls, internet research, or to watch TV. The facility used a business-only internet account for both office and resident use, which violated the provider's policy and led to service suspension. Interviews confirmed that residents were left without internet access for an extended period, and facility leadership was unaware of the full extent and requirements related to resident internet access.
Multiple residents' rooms were found with mice droppings, holes in walls, and food debris, while a common area cabinet contained live and dead roaches with egg sacs. Residents and staff reported frequent sightings of mice, and facility records showed inconsistent pest control services due to a change in vendors, resulting in inadequate pest management.
A resident was transferred to another facility without receiving the required written notice detailing the reason, effective date, new location, or appeal rights. Documentation of communication with the resident, family, physician, and ombudsman was missing, and staff interviews confirmed that the established discharge process and facility policy were not followed.
A resident with multiple medical conditions was referred for cataract surgery, but after a follow-up eye center visit, unclear discharge paperwork stating only 'return for cataract evaluation' was not clarified by nursing staff. As a result, no further appointment was made and the surgery was not scheduled, despite facility expectations that staff should clarify and act on such instructions.
A resident discharged to another skilled nursing facility did not have a comprehensive discharge summary completed, as required by facility policy. The medical record lacked a final summary of the resident's status, medication reconciliation, and a post-discharge care plan. Additionally, the MDS assessment was incomplete regarding discharge goals and referrals, and there was no discharge order from the physician.
A resident with a history of mental illness and requiring 1:1 supervision experienced an escalation in aggressive behavior after being told by an LPN to remain at the nurse's station due to staff shortages, rather than being allowed to go to their room as per their care plan. The lack of sufficient and competent staff, along with failure to follow care plan interventions, led to a physical altercation and the resident being sent to the hospital.
A resident with a mechanical soft diet order was served a regular textured ham sandwich, leading to choking. Staff were unable to clear the airway, and emergency medical staff later dislodged the food. The resident was hospitalized and later expired.
A facility did not follow its abuse and neglect policy by failing to thoroughly investigate an incident where a resident, ordered a mechanical soft diet, was served a regular diet. This error resulted in the resident choking and later dying in the hospital. The incident was part of a sample of 10 residents, with the facility's census at 110.
A resident with a mechanical soft diet order due to swallowing difficulties was served a regular textured ham sandwich, leading to choking and eventual death. The incident was caused by a lack of communication between dietary and nursing staff regarding the resident's dietary needs, resulting in the provision of an inappropriate meal. Despite staff intervention, the resident's airway could not be cleared, leading to hospitalization and death.
A facility failed to investigate a resident's possession of unknown pills and consumption of magnesium citrate, contrary to its abuse and neglect policy. The resident, with no cognitive impairment, was found with foam at the mouth and jerky movements. Staff failed to communicate and act on the incident, with the DON unaware until later. The lack of investigation highlights a breakdown in policy adherence and staff communication.
A facility failed to prevent multiple altercations between two residents, one with moderate cognitive impairment and schizophrenia, and another with no cognitive impairment but exhibiting aggressive behaviors. Despite three incidents, the facility did not update care plans with interventions, nor did it follow its abuse policy to protect residents. Staff interviews indicated that the resident should not have been placed on a hall with more aggressive residents, and the resident was only moved after the third altercation.
During a Covid-19 outbreak, facility staff and visitors failed to comply with the requirement to wear N95 masks, as observed in multiple instances. Despite signage and policy mandates, staff, including CNAs and maintenance workers, as well as external personnel, were seen without masks or wearing them improperly. Interviews confirmed awareness of the requirement, but enforcement was lacking, potentially affecting all 112 residents.
A facility failed to maintain a medication error rate below 5%, resulting in a 22.22% error rate. A CMT administered the wrong inhaler to a resident without instructions and omitted several prescribed medications. Miscommunication after a telehealth visit led to a medication order error, which was corrected after surveyor intervention. The facility's policy on medication administration was not followed.
A significant medication error occurred when a resident received incorrect dosages of Haloperidol due to a transcription failure. The resident was prescribed 5 mg twice a day, but the previous 2 mg three times per day order was not removed, leading to both dosages being administered. The error was identified during a survey, revealing that the CMT did not verify the orders with the Charge Nurse before administration.
A resident with a history of elopement and mental illness symptoms requiring 24-hour monitoring left an LTC facility undetected due to inadequate supervision and malfunctioning exit doors. Staff failed to conduct required hourly checks, and documentation was falsified. The resident was missing for over 24 hours before being found by police. The facility's lack of communication and awareness of the resident's risk contributed to the incident.
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor residents’ rights to choose their own attending physician after discontinuing services with Physician A, who had been providing care to 15 residents. The facility’s Resident Rights policy states that residents have the right to choose a personal attending physician, be fully informed in advance about care and treatment and any changes that may affect their well-being, and participate in planning their care and treatment. Despite this, when corporate notified the Administrator via email that Physician A would no longer have privileges at the facility, the Administrator and DON implemented the change by informing residents and their representatives that their primary physician would be changed, without offering a choice or obtaining resident input. No written notices or letters were sent to residents, responsible parties, or guardians about the physician change. Resident #2, who had no cognitive impairment and diagnoses including stroke, cancer, and diabetes, was documented as having a call placed to a “guardian” about the primary doctor change, even though the medical record contained no documentation of a legal guardian and the resident stated he/she was his/her own guardian and power of attorney. The resident reported being told that Physician A would no longer be at the facility and that he/she had to go with another physician, despite expressing a desire to remain with Physician A. Resident #7, who also had no cognitive impairment and diagnoses including high blood pressure, stroke, and depression, was notified via a progress note that Physician A would no longer have privileges and that he/she would have a new physician. In interview, this resident stated he/she was not asked to change physicians, would have liked to stay with Physician A, and would have appreciated being asked. The DON acknowledged that she informed residents of the change but did not ask if they wanted to change physicians, and both the Administrator and DON stated the resident rights policy should have been followed as written.
Failure to Supervise High-Risk Resident Leading to Unrecognized Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a known history of elopement from prior facilities received adequate supervision and monitoring, resulting in the resident’s absence from the facility going unrecognized for at least 4.5 hours. The resident had diagnoses including schizoaffective disorder, bipolar type, lack of coordination, and muscle weakness, and had a legal guardian. The resident’s care plan identified a problem of elopement risk due to a history of elopement from a prior secure facility, with an intervention for face checks/intensive monitoring per facility protocol. Despite this, the resident’s elopement assessments on two prior dates scored the resident as not at risk for elopement, and no additional elopement risk assessment was completed after the guardian requested that the resident be moved to a secured unit because of prior elopements and recent marijuana use at the facility. On the day of the incident, the resident’s room was located adjacent to an exit door at the end of a hall. Staff accounts showed that the resident was last definitively seen by an LPN between approximately 2:00 P.M. and 2:30 P.M. The resident did not come out to smoke at 11:45 A.M., and later did not come for dinner. Instead of personally checking on the resident, the LPN sent another resident to the room; that resident reported back that the missing resident did not want to be bothered and was asleep, and the LPN did not verify this information before leaving at shift change. The oncoming LPN reported that when the shift began at 7:00 P.M., the resident was already not in the facility, and a CNA informed the oncoming nurse that the resident had not been seen, prompting a search and a code white. The oncoming LPN stated they were unaware of any elopement history for the resident and had not been told the resident might leave. Additional documentation and interviews showed that routine rounds were expected every two hours, primarily by CNAs and CMTs, to ensure residents were present and safe, and that intensive monitoring was understood by some staff to mean constant visual ability to see the resident. However, staff reported that when they believed they knew where residents were, they simply passed that information to the next shift without directly confirming the resident’s presence. The facility’s own investigation noted that a door alarm to the smoking area sounded between approximately 1:15 P.M. and 1:30 P.M., and a CNA obtained a key from the nurse’s station and turned the alarm off, with no documented verification that a resident had exited. The Administrator later stated that the alarm was not reported and that it was unknown whether anyone checked to see if a resident had gotten out. Medication administration records showed multiple scheduled medications, including psychotropic and other chronic medications, were not administered later that day and the following morning, with documentation indicating the resident was out of the building. The resident’s guardian reported that while out of the facility, the resident was not dressed appropriately for the weather, did not have a cell phone or wallet, and later told the guardian that the intent had been to get out for a while, and that the resident was “out of touch” and did not think clearly during this time.
Failure to Thoroughly Investigate Resident-to-Resident Altercation Involving Weapon
Penalty
Summary
Facility staff failed to conduct a thorough investigation of a resident-to-resident altercation in which one resident attempted to stab another with a sharp object, contrary to the facility’s Incidents and Accidents and Abuse and Neglect policies. The policies required use of the electronic risk management system, completion of incident reports for resident-to-resident altercations, obtaining written witness statements, conducting a root cause analysis, and fully investigating all allegations of abuse, including certain resident-to-resident altercations. The policies also required that the facility protect residents during an investigation, document actions taken in the medical record, and revise care plans when residents’ needs or behaviors changed as a result of an incident. In this case, the facility did not follow these procedures after the altercation. Resident #1, who was cognitively intact and diagnosed with a psychotic disorder and schizophrenia, became increasingly violent and aggressive toward staff and another resident on the date of the incident. Nursing documentation initially stated that Resident #1 obtained a screwdriver and attempted to stab another resident, with no physical contact or injury due to immediate staff intervention and initiation of a behavior emergency code. That note was then stricken and rewritten to replace “screwdriver” with “object.” Resident #1 was sent to the hospital for psychiatric evaluation. Resident #2, also cognitively intact and diagnosed with a psychotic disorder and schizophrenia, later reported that Resident #1 pulled a screwdriver from a pocket, tried to “shank” and take Resident #2’s life, and that there was close physical contact, including Resident #2 hitting Resident #1. A CMT who witnessed the event reported that the two residents argued about money, engaged in a physical fight, and that Resident #1 pulled a screwdriver from a back pocket; the CMT stated there was physical contact and that this was also reported to police. Despite these accounts, the facility’s investigation was incomplete and did not comply with policy. The written investigation documented that a behavior code was called for erratic behaviors between the two residents and that staff reported there was almost a resident-to-resident altercation with no harm or physical contact. The Administrator later interviewed Resident #1, who stated that Resident #2 approached after misinterpreting Resident #1’s yelling, and that Resident #1 pulled out a screwdriver and waved it around without making contact, and claimed to have obtained the screwdriver from a maintenance closet. However, the investigation did not include written statements from staff who were involved or witnessed the incident, did not include written statements from either resident, and did not include a statement from the maintenance employee whose cart the screwdriver was allegedly taken from. There was no documentation that either resident’s care plan was updated to reflect the altercation or to add interventions, and Resident #2’s nurses’ notes contained no documentation of the incident. The Administrator acknowledged that an investigation should have been done, that she was not initially aware of the object or attempted stabbing as documented in the progress note, and that no in-service education or comprehensive investigation had been completed prior to the on-site surveyor investigation. The facility’s failure to follow its own incident and abuse policies extended to documentation and care planning. Resident #1’s care plan in use at the time of the investigation contained no documentation or interventions related to the most recent resident-to-resident altercation, and no interventions were added before the on-site investigation. Resident #2’s care plan similarly lacked any documentation or interventions related to the altercation, and there were no nursing notes describing the event for Resident #2. The facility’s Abuse and Neglect policy required investigation of all allegations and types of incidents listed, including certain resident-to-resident altercations, and required that the Administrator or designee complete an administrative investigation with personal statements, root cause, and a plan of action. The Administrator later stated there was no investigation, that she only considered the clinical aspects such as sending the resident out and completing risk management documentation, and that she did not obtain statements from others involved. These omissions demonstrate that the facility did not operationalize its policies for prevention, identification, investigation, and reporting of abuse and resident-to-resident altercations in this incident.
Incomplete Facility-Wide Assessment and Staffing Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not address required staffing ratios per shift, the need for a Registered Nurse (RN) for at least eight consecutive hours daily, or the designation of an RN as the Director of Nursing (DON). Additionally, the assessment lacked documentation regarding the ratios of direct care staff, restorative therapy staff, social services staff, dietary staff, housekeeping, and laundry staff needed on each shift to meet resident needs. There was also no information provided about staff competencies and skill sets required to care for the resident population. The facility's policies and admission agreements indicated that it serves residents with skilled nursing needs, including those with Alzheimer's disease, dementia, and other complex medical and behavioral conditions. The facility's resident matrix showed a diverse population with diagnoses such as Alzheimer's/dementia, hospice care, dialysis, intravenous therapy, PTSD/trauma, and various medication requirements, including insulin, anticoagulants, antianxiety, antipsychotic, antidepressant, and hypnotic medications. Despite these complex care needs, the facility did not have a full-time DON or a full-time social worker or social service designee at the time of the survey. During the survey, the administrator acknowledged responsibility for completing the facility assessment but stated that it was incomplete due to missing maintenance and nursing information. The only documented information in the assessment pertained to contact information for external resources or when to use another facility, rather than a thorough evaluation of internal resources and staffing. As a result, the facility did not have a complete or thorough facility-wide assessment as required.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance and cleanliness of resident areas. Numerous rooms and shared bathrooms had unpainted drywall, exposed holes, missing or damaged cove base, and crumbling drywall. Several rooms had holes in the walls, some with visible mice droppings and black, hairy-like substances protruding. There were also instances of overhead bed light covers missing, exposing light bulbs, and air conditioning units with gaps between the unit and the wall. Shared bathrooms had chipped and cracked paint, brown stains, and sinks pulled away from the wall with cracked paint and caulk. Floors in several rooms and bathrooms were described as dirty and sticky, with baseboards pulled away from the walls and plaster peeling. A broken ceiling tile near the D-hall entrance exposed electrical wires and the space above the ceiling tiles. During interviews, the Maintenance Assistant explained that staff are required to fill out work order sheets for repairs, which are collected daily. However, the Maintenance Assistant stated that due to budget cuts, the supplies needed to make repairs are slow to arrive, contributing to the ongoing issues with the facility's environment. The observations and interviews indicate that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents throughout the building.
Failure to Provide Full-Time DON Not Serving as Charge Nurse with Census Over 60
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse when the resident census exceeded 60, as required by both facility policy and federal regulations. At the time of the survey, the census was 105 residents. The facility's policy defined full-time as 40 or more hours per week and specified that the DON may only serve as a charge nurse if the census is 60 or fewer. Review of staffing records and interviews revealed that the DON was on medical leave, and there was uncertainty among staff regarding who was fulfilling the DON role during this period. The RN Supervisor was identified as the interim DON, but also provided RN coverage on several days, which conflicted with the policy prohibiting the DON from serving as a charge nurse when the census is above 60. Further interviews confirmed that on specific days, the facility did not have an interim DON present, and RN staff from corporate provided coverage intermittently. The lack of a consistent, full-time DON who was not also serving as a charge nurse was discussed in the facility's QAPI meeting, and there was consideration of the DON performing some duties remotely. However, at the time of the survey, the facility was not in compliance with the requirement for a full-time DON who was not assigned as a charge nurse, given the census of 105 residents.
Failure to Accurately Reconcile Resident Trust Fund Accounts
Penalty
Summary
The facility failed to maintain an accurate and properly reconciled accounting system for resident trust fund accounts, as required by their own policy and proper accounting principles. Review of facility records showed that monthly reconciliations of the resident trust fund were either not completed or, when attempted, did not match the residents' current balances. Bank statements and reconciliation forms from several months revealed discrepancies, including unexplained differences between the reported cash on hand and the actual cash counted in the safe. For example, the bank reconciliation reports showed significantly higher cash on hand amounts than what was physically present. Interviews with the Business Office Manager (BOM), Activity Director (AD), and Corporate Business Office Manager (CBOM) confirmed inconsistent practices in tracking and reconciling petty cash, which is drawn from the resident trust fund. The BOM and AD described daily and monthly cash counts and receipt tracking, but were unable to explain the discrepancies between the physical cash and the amounts reported on reconciliation forms. The administrator and CBOM both stated expectations that the petty cash and trust fund accounts be accurately reconciled each month, but this was not occurring in practice.
Resident Placed in Unauthorized Head Lock During Behavioral Incident
Penalty
Summary
A deficiency occurred when a resident's right to be free from physical abuse was violated after a staff member, Floor Tech N, placed the resident in a head lock during an altercation. The incident began when the resident, who had diagnoses including depression and schizophrenia and was noted to have intact cognition, became physically aggressive. The resident first engaged in a resident-to-resident altercation during a smoke break, after which he was placed on 1:1 supervision. While being escorted back inside by Floor Tech N, the resident attacked a CNA, who was also Floor Tech N's family member, by hitting and pulling hair. In response, Floor Tech N intervened by grabbing the resident from behind and placing him in a head lock, which is not an approved restraint technique according to the facility's policies and CPI training protocols. Multiple staff interviews confirmed that Floor Tech N used a head lock to restrain the resident, and that the proper CPI technique was not followed. The resident reported being choked and stated that Floor Tech N threatened him verbally. Other staff present during the incident indicated that there was confusion and fear among staff, with some not intervening as expected. The Administrator and Staffing Coordinator both noted that Floor Tech N did not de-escalate the situation as directed and did not use the correct CPI-approved restraint methods. The Administrator was also physically attacked by the resident after the restraint was released, and staff struggled to manage the situation safely. The facility's policies require that all residents be protected from abuse, including improper use of physical force or restraint, and that staff use only approved de-escalation and intervention techniques. Despite having completed CPI training, Floor Tech N did not adhere to these protocols, resulting in the use of an unauthorized physical restraint. The incident was further complicated by the involvement of Floor Tech N's family member and the lack of coordinated staff response, which contributed to the violation of the resident's rights and the facility's failure to prevent abuse.
Unauthorized Use of Resident Trust Funds
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's patient trust funds, resulting in unauthorized withdrawals totaling $7,877.01 over a one-week period. The Business Office Manager (BOM) withdrew funds from the resident's account to make purchases, including clothing, furniture, and a recliner, without first obtaining the resident's permission or signature as required by facility policy. The BOM relied on input from Certified Nurse Aides (CNAs) regarding what the resident might need and proceeded with purchases without direct resident involvement or consent. The BOM also admitted to forgetting to have the resident sign the ledger receipt for a cash withdrawal given for shopping with family. The resident, who had no cognitive impairment but diagnoses including schizophrenia, anxiety disorder, depression, and dementia, stated that they did not authorize the purchases and did not want several of the items bought with their funds. Observations confirmed that some purchased items were not present in the resident's room, and some items, such as a recliner, were unwanted by the resident. The facility's policy required resident consent and signatures for all withdrawals, which was not followed in this case.
Failure to Ensure Hospice Enrollment and Timely Physician Notification
Penalty
Summary
A resident with multiple serious diagnoses, including COPD, kidney disease, heart failure, lung cancer, and dementia, was re-admitted to the facility with hospital discharge orders recommending a hospice evaluation and referral. The care plan and physician documentation indicated that the resident had elected hospice services, and interventions were outlined to work cooperatively with hospice to maintain comfort. However, the resident was not actually enrolled in hospice services upon re-admission, and no hospice orders were documented in the re-admission physician orders. Progress notes indicated that the hospice referral was initially made, but the referral was closed and a new referral was to be sent to a different hospice provider. There was no documentation confirming the resident's enrollment in hospice services prior to their decline and subsequent death. On the day of the resident's decline, staff noted a significant change in condition, including low blood pressure, irregular breathing, and low oxygen saturation. The LPN on duty attempted to contact the next of kin and notified the physician of the resident's declining status, but did not inform the physician that the resident was not enrolled in hospice services after discovering this fact. The LPN also failed to document the assessment and vital signs in the medical record, instead writing them on a piece of paper and forgetting to enter them later. The resident expired several hours after the change in condition, and there was no evidence that hospice services were initiated or that the physician was made aware of the lack of hospice enrollment. Interviews with facility staff and the physician confirmed that there was an expectation for the resident to be on hospice services, and that the physician should have been notified if the resident was not enrolled. The physician stated that, had he been informed, he would have considered sending the resident to the hospital for evaluation and treatment. The facility's policy required clinicians to be notified of changes in condition and for all assessments and vital signs to be documented in the medical record, but these procedures were not followed in this case.
Failure to Administer Physician-Ordered Pain Medication
Penalty
Summary
Facility staff failed to implement an effective pain management regimen for a resident who had a physician's order for Percocet 5/325 mg every four hours as needed for pain. Despite the order being present on the resident's Physician Order Sheet and care plan, staff did not administer the medication at any point during the months reviewed. The Medication Administration Record showed no documentation of Percocet being given, and progress notes did not indicate its use. Instead, the resident received Tylenol intermittently, which was documented as administered on select dates, but the stronger, physician-ordered medication was not provided. The resident, who had diagnoses including high blood pressure, dementia, schizophrenia, and depression, reported experiencing severe back pain that affected mobility and radiated down the leg. The resident stated that Tylenol was not effective and expressed a need for stronger pain relief, but was told by staff that only Tylenol was available. Interviews with staff revealed that the CNA reported the resident's pain to the nurse, and the LPN was unaware of the Percocet order, stating that it was not available on the medication cart and had never been administered. The interim Director of Nurses and the Administrator both confirmed they were unaware of the Percocet order, with the Administrator noting that the order had never been sent to the pharmacy. Facility policy required a systematic approach to pain recognition, assessment, and management, including administering medications as ordered and monitoring their effectiveness. However, the failure to transcribe and process the Percocet order resulted in the resident not receiving the prescribed pain management, despite ongoing complaints of severe pain and repeated communication with pain management providers.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was cited under F689 for failure to ensure that an area of the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The citation remains uncorrected, as referenced in the current and previous survey events. Specific details regarding the actions or inactions that led to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency is ongoing, with references to previous uncorrected citations and supporting documentation in earlier statements of deficiencies.
Failure to Maintain 1:1 Supervision for High-Risk Resident Resulting in Self-Harm
Penalty
Summary
A resident with a documented history of major depressive disorder, anxiety disorder, PTSD, and repeated self-harming behaviors was assessed as high risk for suicide, with multiple recent incidents of self-harm and a high score on the Columbia Suicide Severity Rating Scale. The resident's care plan required 1:1 monitoring and close supervision, defined as staff being within three to five feet of the resident at all times, and removal of items that could be used for self-harm. Despite these interventions, the resident was left unsupervised in their room with the door closed when the staff member assigned to provide 1:1 supervision was reassigned to other duties due to short staffing. During the period the resident was left alone, they broke the window in their room and used a piece of glass to inflict multiple deep cuts on themselves, requiring medical intervention. Staff discovered the incident during routine rounds, and interviews confirmed that the resident was left unsupervised for approximately 15 to 20 minutes. The resident reported taking advantage of the absence of supervision to harm themselves, and staff interviews corroborated that 1:1 supervision was not maintained as required by the care plan and facility policy. Facility policies on supervision and suicide prevention explicitly required that residents at high risk for self-harm not be left alone and that 1:1 supervision be maintained at all times, with staff responsible for ensuring coverage if they needed to leave. Multiple staff and administrative interviews confirmed that the expectation was for continuous supervision, and that the failure to maintain 1:1 supervision directly led to the resident's opportunity to self-harm. The deficiency was identified as Immediate Jeopardy due to the facility's failure to provide adequate supervision and prevent a serious accident.
Resident Not Allowed to Participate in Care Planning During Transfer and Secured Unit Placement
Penalty
Summary
A deficiency occurred when a cognitively intact resident with a history of sex offender status was admitted to the facility and immediately placed on a secured/locked unit without being allowed to participate in the development or implementation of their person-centered plan of care. The resident was transferred from a sister facility without being informed of the transfer, not given any paperwork, and not consulted about their preferences or options for placement. Upon arrival, the resident was visibly upset, expressed not wanting to be at the facility, and reported not understanding why they were placed in a locked unit or why the transfer occurred. Facility policy required sex offenders to be placed on a locked unit, but there was no documentation in the resident's care plan or medical record regarding the rationale for this placement, any assessment of risk, or communication with the resident about the transfer and placement. The resident's medical record showed no evidence of recent or past sexually aggressive or abusive behaviors, and the care plan did not address the secured unit placement. The resident was described as having no unwanted behaviors and was adjusting well, with no documentation of behavioral issues that would warrant such restrictive placement. Interviews with facility staff, including the Social Service Director and Regional Nurse Director of Operations, confirmed that the transfer and admission process was not conducted properly. The resident was not given the opportunity to express their preferences or participate in care planning, and the decision to place the resident on the locked unit was based solely on their sex offender status, contrary to facility policy requirements for individualized assessment and anti-discrimination laws.
Resident Placed on Locked Unit Without Clinical Justification Due to Sex Offender Status
Penalty
Summary
A resident, who was cognitively intact and their own responsible party, was placed on a secured/locked unit within the facility solely due to their status as a registered sex offender. There was no clinical justification, assessment, or documentation indicating that the resident met the criteria for admission to a secured unit. The facility's policy required sex offenders to be placed on the locked unit, but the policy itself stated that placement decisions should be based on risk assessment and not solely on registry status. The resident had no documented history of sexually aggressive or abusive behaviors, and medical records showed no behavioral issues or risk assessments related to sexual abuse. The resident expressed not wanting to be at the facility, was not informed about the transfer, and did not receive any paperwork or options regarding their placement. Interviews with facility staff, including the Social Service Director and the Regional Nurse Director of Operations, confirmed that the resident was transferred from a sister facility without proper discharge or admission procedures. Staff acknowledged that the resident was upset, unaware of the transfer, and not given the opportunity to choose their placement or receive their belongings. Documentation in the resident's care plan and medical record did not address the placement on the secured unit, and there was no evidence of an individualized assessment to justify the restriction. The facility's actions were based on a blanket policy for sex offenders rather than an individualized evaluation, resulting in the resident being confined to a locked unit without appropriate clinical or legal basis.
Failure to Provide Resident Access to Electronic Communications Due to Lack of WiFi
Penalty
Summary
The facility failed to ensure residents had reasonable and reliable access to, and privacy in, their use of electronic communications, including email, video communications, internet research, and television viewing, due to the lack of WiFi services. Documentation showed that the facility was notified by its Internet Provider of a violation of the Acceptable User Policy after sharing its business/office-only internet with residents, which was not permitted under the provider agreement. Despite multiple notifications from the provider, the facility continued to allow residents to use the business internet, resulting in the suspension and eventual disconnection of internet services. At the time of the survey, some residents still did not have internet access. Interviews with residents revealed that they were unable to watch TV, listen to music, or use the internet for an extended period, though they could not specify the exact duration. The Administrator acknowledged being unaware of the length of the issue and stated that the facility did not have the correct internet account to support resident use. The Regional Nurse Consultant also indicated a lack of awareness regarding the requirement to provide WiFi to residents. The Internet Provider confirmed that the facility was in breach of its agreement by sharing the business internet with residents and that a bulk service package was needed for resident use.
Failure to Maintain Effective Pest Control in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of mice, mice droppings, and roaches in multiple resident rooms and a common area. Observations revealed mice feces in the rooms of three residents, with one room also having a visible hole in the wall and separated cove base, and another room containing a chocolate chip cookie on the floor near mice droppings. Residents reported seeing mice in their rooms and noted that staff did not clean areas where droppings were present. Staff interviews confirmed sightings of mice in various areas, including resident rooms and hallways, and one staff member was unaware of a system for reporting pest sightings. In the common/activity area, live and dead roaches with egg sacs were found inside a cabinet, further indicating inadequate pest control measures. Review of facility records showed that the pest control policy required regular services from a qualified vendor, but only two recent invoices were available, with a gap in service after the previous pest company stopped coming. The new pest control company had only recently started, and there was no documentation of consistent pest control services during the interim. The administrator acknowledged the expectation for a pest-free environment, but the facility was unable to provide evidence of ongoing, effective pest management during the period in question.
Failure to Provide Required Written Notification Prior to Resident Transfer
Penalty
Summary
The facility failed to provide proper written notification to a resident prior to a transfer or discharge, as required by both facility policy and federal regulations. Specifically, the resident, who was cognitively intact and their own responsible party, was transferred to a sister facility without receiving a written notice detailing the reason for the move, the effective date, the new location, or information about the right to appeal the decision. There was also no evidence that the required notifications were sent to the resident representative or the Office of the State Long-Term Care Ombudsman. Record review revealed that the resident's care plan included interventions to address potential relocation stress, but there was no updated documentation reflecting the resident's desires or needs regarding the transfer. Progress notes indicated that the resident was spoken to about relocating and was discharged the following day, but there was no documentation of written notification, family or physician notification, medication reconciliation, or ombudsman notification. Additionally, there was no evidence of referral inquiries or discussions with the resident or prospective facilities about the transfer. Interviews with facility staff confirmed that the established discharge process was not followed. The Social Services Director acknowledged that documentation related to discharge communications and referrals was expected but not present. The Regional Nurse Director of Operations also stated that the process was not followed, the resident was not offered other placement options, and communications with the resident and family were not properly documented. The facility's own policy requires comprehensive written notification and documentation, which was not adhered to in this case.
Failure to Clarify Discharge Instructions Delays Cataract Surgery Scheduling
Penalty
Summary
Facility staff failed to meet professional standards by not clarifying unclear discharge instructions from an eye clinic for a resident who had been referred for cataract surgery. The resident, who was cognitively intact and had diagnoses including diabetes, thyroid disorder, and schizophrenia, was seen by an optometrist and referred to an ophthalmologist for cataract surgery in both eyes. The resident attended a follow-up appointment at the eye center, but the discharge paperwork only stated 'return for cataract evaluation' without specifying a date, location, or procedure, and did not include contact information for further clarification. Upon return to the facility, the assigned nurse did not seek clarification from the eye center regarding the next steps for the resident's care, as the discharge paperwork lacked specific instructions. Interviews with staff revealed that the nurse was responsible for reviewing discharge paperwork and making necessary follow-up appointments, but in this case, no action was taken due to the lack of clear instructions. The medical records staff uploaded the paperwork to the resident's electronic medical record, but also did not follow up, as she was unaware of the need for a return visit to the eye center for surgical evaluation. Multiple interviews with facility leadership, including the Administrator, DON, and medical staff, confirmed that their expectation was for nursing staff to clarify any unclear discharge instructions and ensure appropriate follow-up. However, this did not occur, resulting in the resident's cataract surgery not being scheduled as intended. The failure to clarify and act on the discharge instructions directly led to the deficiency cited in the report.
Incomplete Discharge Summary and Communication at Resident Discharge
Penalty
Summary
Facility staff failed to complete a comprehensive discharge summary for one resident who was discharged to another skilled nursing facility. Review of the resident's closed medical record showed that the discharge summary was incomplete, lacking a final summary of the resident's status, a reconciliation of all pre- and post-discharge medications, and a post-discharge plan of care. The resident's physician order sheet did not contain a discharge order, and the Minimum Data Set (MDS) assessment had unanswered sections regarding the resident's overall goal and whether a referral had been made to the local contact agency. According to facility policy, a discharge summary must be provided upon a resident's discharge, addressing discharge goals, needs, caregiver support, and referrals, and must include a recapitulation of stay and medication reconciliation. The Director of Nursing confirmed that the discharge summary should include information from all departments, medication lists, recapitulation of stay, home health orders, and follow-up appointments, but these elements were missing from the resident's record.
Failure to Provide Sufficient and Competent Staff for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient and competent staff were available to meet the behavioral health needs of a resident who required 1:1 supervision for safety and behavioral concerns. The resident, who had diagnoses including anxiety disorder, depression, and bipolar disorder, was care planned for close monitoring, avoidance of power struggles, and consistent routines to manage symptoms. On the night in question, the assigned 1:1 staff left before the replacement arrived, leaving the resident without the required supervision. As a result, the resident was brought to the nurse's station and told by an LPN that they would have to remain there until the 1:1 staff arrived or potentially all night. The resident expressed a desire to go to their room to sleep, but the LPN insisted the resident remain at the nurse's station, citing the lack of available staff. This interaction escalated, with the resident becoming increasingly agitated and ultimately aggressive, leading to a physical altercation with the LPN. The situation further deteriorated when the resident attempted to leave, threw objects, and fell from their chair, prompting a call to emergency services and the resident being sent to the hospital. Interviews with staff and review of staffing records confirmed that the facility was short-staffed at the time, and the LPN involved was relatively new and had not effectively implemented the care plan interventions, such as avoiding power struggles and ensuring the resident's needs were met. The failure to provide appropriate supervision and to follow the resident's care plan directly contributed to the escalation of the resident's behavior and the subsequent incident requiring hospital transfer.
Failure to Serve Correct Diet Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident, who required supervision, was served the correct diet as ordered by the physician. The resident had a physician's order for a mechanical soft texture diet, which is food altered to be soft and easy to chew. However, during lunch, staff served the resident a regular textured ham sandwich. As a result, the resident began to choke, and staff were unable to completely clear the resident's airway. Emergency medical staff eventually dislodged several pieces of regular textured thinly sliced meat, but the resident was hospitalized and subsequently expired.
Failure to Investigate Diet Error Leading to Resident's Death
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy by not conducting a thorough investigation following an incident involving a resident who was served an incorrect diet. The resident, who had an order for a mechanical soft diet, was mistakenly given a regular diet, leading to choking and subsequent death in the hospital. This incident was part of a sample of 10 residents, with the facility having a total census of 110.
Failure to Provide Correct Diet Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident who required supervision was served the correct diet as ordered by the physician. The resident, who had a mechanical soft diet order due to a condition that caused swallowing difficulties, was served a regular textured ham sandwich instead of the prescribed mechanical soft meal. This led to the resident choking, and despite staff intervention, the resident's airway could not be completely cleared, resulting in hospitalization and eventual death. The incident occurred when the resident refused the mechanical soft lunch provided and requested sandwiches. A Certified Medication Technician (CMT) requested sandwiches from the dietary staff but did not specify the need for a mechanical soft consistency. Consequently, the resident was given regular ham and cheese sandwiches, which were not suitable for their dietary needs. The dietary staff did not inquire about the resident's dietary requirements, and the nursing staff failed to communicate the resident's specific diet order. Interviews with various staff members revealed a lack of communication and verification regarding the resident's dietary needs. The dietary manager and staff confirmed that the sandwiches provided were of regular consistency, and the Registered Dietitian emphasized that sliced meat should never be served to a resident on a mechanical soft diet. The Speech Therapist noted that the resident was at risk for aspiration and should have been supervised during meals. The failure to adhere to the prescribed diet and provide adequate supervision directly contributed to the resident's choking incident and subsequent death.
Failure to Investigate Resident's Possession of Unknown Pills and Solution
Penalty
Summary
The facility failed to follow its abuse and neglect policy by not conducting a thorough investigation into an incident involving a resident who was found with unknown pills and allegedly consumed a bottle of magnesium citrate. The resident, who had no cognitive impairment and was independent in activities of daily living, was found on the ground with foam coming from his mouth and exhibiting semi-jerky movements. Despite the resident's claim that the pills and solution were given by a hospital doctor, there was no documentation of an investigation into the origin of these items or the circumstances surrounding their consumption. Interviews with staff revealed a lack of communication and action regarding the incident. A CNA witnessed the resident shaking and called a code blue, but did not see the resident consume any pills or solution. An RN took a picture of the pills and solution and sent it to management but did not initiate an investigation. The LPN who admitted the resident did not inquire about any medications or solutions the resident might have had, and the RCC did not report the incident to the DON, believing it was unnecessary. The DON was unaware of the incident until much later and stated that an investigation would have been initiated had she been informed. The Administrator and Regional Nurse Consultant also expected an immediate investigation. The lack of a timely and thorough investigation into the incident represents a failure to adhere to the facility's policies on abuse and neglect, as well as a breakdown in communication among staff members.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by multiple altercations between two residents. Resident #2, who had moderate cognitive impairment and diagnoses including schizophrenia, was involved in three altercations with Resident #3, who had no cognitive impairment but exhibited physical and verbal behaviors. These incidents occurred on 4/29/24, 8/17/24, and 9/1/24, with Resident #2 being physically assaulted by Resident #3. Despite these altercations, the facility did not update the care plans for either resident with appropriate interventions after each incident. The facility's Abuse and Neglect Policy mandates immediate reporting of abuse allegations and protective measures during investigations. However, the facility did not adhere to these guidelines, as evidenced by the lack of timely intervention and care plan updates following the altercations. The policy also requires that residents who allegedly mistreat others be removed from contact during investigations, but Resident #2 was only moved to another hall after the third altercation on 9/1/24. Interviews with staff, including an LPN and a Hall Monitor, revealed that Resident #2 should not have been placed on a hall with more aggressive residents. The Director of Nursing acknowledged that Resident #2 had aggressive behaviors and expressed that the resident should have been moved sooner. The facility's failure to follow its abuse policy and update care plans contributed to the ongoing risk of resident-to-resident altercations.
Inadequate Enforcement of N95 Mask Usage During Covid-19 Outbreak
Penalty
Summary
The facility staff failed to adhere to infection control practices, specifically regarding the use of N95 masks during an active Covid-19 outbreak. Observations revealed that despite signage at the entrance indicating the presence of Covid-19 and the requirement for all staff and visitors to wear N95 masks, compliance was not maintained. Several staff members, including Certified Nurse Aides and maintenance workers, were observed either not wearing masks or wearing them improperly. Additionally, external personnel such as pest control workers and a soda vendor were seen in the facility without masks, despite acknowledging the signage. Interviews with staff and external workers confirmed awareness of the mask requirement due to the Covid-19 outbreak. However, there was a lack of enforcement or instruction from the facility staff to ensure compliance. The facility's policy on Personal Protective Equipment, updated in June 2024, mandates the use of N95 masks to prevent the transmission of airborne pathogens, yet this policy was not effectively implemented, potentially affecting all 112 residents in the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 22.22% error rate. This deficiency was identified through observation, interview, and record review. During a medication administration observation, a Certified Medication Technician (CMT) administered the wrong inhaler to a resident and failed to provide instructions for its use. Additionally, the CMT did not administer several prescribed medications, including Lasix, Meloxicam, and Sertraline. The CMT acknowledged the errors and reported them to the Charge Nurse after the administration. The errors were compounded by a miscommunication following a telehealth visit, where a Nurse Practitioner was unable to enter a medication order change. The Assistant Director of Nurses (ADON) entered a new order for Haloperidol but failed to remove the previous order, leading to a medication error. The Director of Nursing (DON) confirmed the error and stated that it was corrected after being brought to the facility's attention by the surveyor. The facility's Medication Administration Policy emphasizes the importance of following the six rights of medication administration and reporting discrepancies immediately, which was not adhered to in this instance.
Significant Medication Error Due to Transcription Failure
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was prescribed antipsychotic medication. The error occurred when staff did not correctly transcribe the physician's orders for the resident's medication. The resident was supposed to receive Haloperidol 5 mg twice a day, as ordered on 6/21/24, but the previous order of Haloperidol 2 mg three times per day was not removed from the Medication Administration Record (MAR). This resulted in the resident receiving both dosages, leading to an incorrect total dosage of the antipsychotic medication. The error was identified during a survey when it was observed that the resident was administered both 2 mg and 5 mg doses of Haloperidol. The Certified Medication Technician (CMT) involved reported the medication administration to the Charge Nurse only after administering the medication, rather than verifying the orders beforehand. The Director of Nursing (DON) confirmed that the error stemmed from a failure to update the MAR correctly after a telehealth visit, where the Nurse Practitioner was unable to enter the order change directly and communicated it via email to the Assistant Director of Nurses (ADON), who then failed to remove the outdated order.
Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a history of elopement, hallucinations, and mental illness symptoms requiring 24-hour monitoring. The resident was able to leave the facility without staff knowledge, as staff failed to conduct visual checks and follow up on the resident's whereabouts. The resident was missing for over 24 hours before being located by a local police department. The resident had a documented history of elopement risk, and assessments consistently identified them as at risk. Despite this, the facility's staff did not perform the required hourly face checks, and documentation was falsified to indicate checks were completed when they were not. Additionally, the facility's exit doors were not functioning properly, allowing the resident to leave the premises undetected. Interviews with staff revealed a lack of awareness and communication regarding the resident's risk and recent move from a locked unit to a main area. The resident's family had expressed concerns about the resident's anxiety and desire to leave, but this information was not effectively communicated to the facility. The facility's failure to ensure proper door security and staff supervision contributed to the resident's elopement.
Removal Plan
- Conducted an investigation and in-serviced staff regarding Code white, secured doors, shift reports and rounds, falsifying documentation.
- Completed elopement assessments on all residents to ensure appropriate placement.
- Monitored exit doors one on one until verified all working properly.
- Charge nurses do checks and document.
- Management audits face check documentation.
- Administrator created a department head rotation schedule for completing random rounds in the facility to include evening and night shift.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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