Hidden Lake Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 11728 Hidden Lake Drive, Saint Louis, Missouri 63138
- CMS Provider Number
- 265735
- Inspections on file
- 23
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hidden Lake Health Care Center during CMS and state inspections, most recent first.
The facility failed to transcribe and implement physician orders, resulting in missed medication changes and laboratory testing for two residents. One resident with multiple conditions, including anemia, hypertension, seizure disorder, and bipolar disorder, had physician orders for routine labs, an autoimmune profile, initiation of doxycycline, discontinuation of lithium, and a lithium level check, but the EMR continued to show an active lithium order and lacked any entries for the new medication or labs. Another resident with diabetes and depression had physician orders for routine lab studies that were never entered or completed, and reported that no blood draw had occurred. Staff interviews showed that an LPN was unaware of the new orders, another LPN believed all new orders were sent to the DON for EMR entry, and the DON and Administrator both stated they were unaware that these physician orders had not been followed.
A resident with severe cognitive impairment and mobility limitations, who required two-person Hoyer lift transfers per care plan, was improperly transferred by staff—once with a gait belt instead of a lift, and later with a Hoyer lift operated by only one CNA. These actions, contrary to facility policy and training, resulted in the resident sustaining a head hematoma and a fractured tibia, as confirmed by hospital evaluation.
A resident with a right foot fracture did not receive proper investigation or family notification by the facility. The staff failed to follow the facility's guidelines for incident investigation and did not fully implement hospital care instructions. Confusion over physician orders led to incorrect treatment, and the family was not promptly informed of the resident's condition. Interviews revealed a lack of adherence to policies and procedures, contributing to the deficiency in care.
A resident with multiple medical conditions, including unhealed pressure ulcers, did not receive proper wound care as per physician orders and facility policy. The resident was observed without required heel protector boots and dressing, and staff interviews revealed a lack of awareness of updated wound care orders. The facility's administrator emphasized the importance of reviewing orders and progress notes, but the deficiency occurred due to non-compliance with these expectations.
The facility failed to segregate resident funds from its operating account, affecting 26 residents. A review revealed that significant amounts of personal funds were improperly held, totaling $164,763.34. The Business Office Manager acknowledged some funds as valid credits needing refunds, while others required further investigation. The Administrator was unaware of these credit balances.
The facility failed to maintain a sufficient surety bond to protect resident funds. A review showed an average monthly balance of $19,158.19 in the Resident Trust Bank Statements, while the Accounts Receivable Aging Report indicated a balance of $164,763.34. The facility only had an approved bond of $30,000, insufficient by $246,000. The Administrator was unaware of the credit balances and stated that corrections would be made.
Two residents experienced unsafe transfers due to staff failing to follow safe practices, respond to requests for assistance, and properly use gait belts. One resident fell from a raised bed and sustained multiple injuries after a CNA attempted to move them alone on a low air loss mattress, despite the resident's request for a second staff member. Another resident, unable to support their own weight, was transferred by two CNAs using a loose gait belt and improper lifting techniques. Staff interviews revealed confusion and inconsistent documentation regarding required assistance levels and transfer status.
The facility did not provide timely access to its EMR system for a state Surveyor during an on-site investigation and also failed to grant hospice providers access to a resident's medical records, despite documented consent and contractual agreements. The hospice team was repeatedly denied both electronic and printed records, impacting their ability to coordinate care for a resident with severe cognitive deficits and multiple diagnoses.
The facility failed to monitor and report changes in condition for two residents and one closed record. A resident with congestive heart failure experienced unreported weight gain and respiratory changes, leading to hospitalization. Another resident showed confusion and motor issues, with critical labs not communicated to the physician timely, resulting in hospitalization for acute kidney failure and UTI. Additionally, a urinalysis was not ordered for a resident who later developed a kidney infection.
A resident readmitted with a Stage II pressure ulcer experienced worsening of the condition due to the facility's failure to conduct wound measurements, transcribe hospice orders, and notify the physician. The resident, at high risk for pressure injuries, developed additional wounds that were not properly documented or treated. Staff failed to follow protocols, leading to a progression of the ulcer to Stage III.
The facility failed to maintain proper food safety standards, with walk-in cooler temperatures exceeding safe limits and dishwashing equipment out of order, leading to potential cross-contamination. The kitchen and kitchenette areas were unclean, with food items improperly labeled and stored, affecting all residents consuming food from the facility.
The facility did not develop or implement a QAPI program, potentially affecting all 53 residents. The Administrator, who started in March 2024, acknowledged the absence of a facility-specific QAPI plan and cited emergency issues as a reason for the delay. A planned QAPI committee meeting in July 2024 was not organized.
The facility failed to maintain a safe and homelike environment, with issues such as inadequate lighting, chipped paint, torn drywall, and strong urine odors in resident rooms. Staff interviews revealed a lack of awareness and communication regarding maintenance issues, with the DON and Administrator unaware of the extent of deficiencies. The Housekeeping Supervisor acknowledged the odor problem and initiated a deep cleaning program, but systemic issues with communication and maintenance processes were evident.
The facility failed to encode and transmit MDS assessments within the required 7 days for several residents. The MDS Coordinator faced challenges with the electronic medical record system, which delayed the transmission process. Interviews with the DON and Administrator revealed they were unaware of the transmission issues, and the Coordinator had to manually verify each resident's MDS status, leading to non-compliance with federal and state regulations.
The facility failed to ensure proper dialysis care and documentation for two residents requiring dialysis. One resident lacked communication records with the dialysis center and had no orders for pre or post-dialysis assessments. Another resident had no orders specifying dialysis days or location. The facility also lacked a policy for assessments, monitoring, and communication with dialysis centers.
The facility failed to conduct comprehensive risk-benefit assessments for siderail use for seven residents, leading to potential safety risks. Residents with conditions such as dementia and hemiplegia had siderails installed without documented assessments. Interviews with staff revealed a lack of awareness and systems for assessing and maintaining siderails, indicating a systemic issue in the facility's approach to siderail safety.
The facility did not maintain the required RN coverage for 8 consecutive hours daily, 7 days a week, as revealed by the PBJ staffing report for Q2 2024. The report showed multiple days with no RN hours, resulting in a one-star staffing rating. The administrator indicated that the previous DON might not have recorded their RN hours correctly, contributing to the deficiency.
The facility failed to properly contain waste, with trash cans in the kitchen and SNF dish room left uncovered and overflowing. Flies were observed in food preparation areas, and an insect light was off due to incorrect bulbs. The Administrator and ADM acknowledged the issue, noting that trash cans should be covered to prevent flies.
A facility failed to document hospice orders and integrate a hospice plan of care into a resident's overall care plan. Despite the resident being admitted to hospice services, necessary orders and treatments were not documented in the ePOS, and the care plan did not reflect hospice services. Interviews revealed a lack of communication between the facility and hospice provider, contributing to the deficiency.
The facility failed to offer and document influenza vaccinations for two residents, despite CDC guidelines. One resident with severe cognitive impairment and another who was cognitively intact did not receive the vaccine, and there was no documentation of education or refusal. The infection control nurse admitted that several residents were not offered the vaccine or the option to decline, revealing a lapse in the facility's vaccination program.
The facility failed to provide the required SNF-ABN or denial letters for two residents upon discharge from Medicare Part A services. Staff interviews revealed a lack of awareness and responsibility for issuing these notices, with the SSD and MDS Coordinator both unaware of their distribution. The Administrator was also unaware of the deficiency.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately listed Alzheimer's as the only diagnosis, omitting other conditions like vascular dementia and hypertension. Another resident's MDS left the dialysis treatment section blank, despite receiving hemodialysis thrice weekly. The administrator expected accurate MDS documentation.
A facility failed to implement a baseline care plan for a newly admitted resident within the required timeframe. The resident had several physician's orders, including hospice evaluation and wound care treatments, which were not incorporated into a baseline care plan. Interviews with staff revealed a lack of clarity and responsibility regarding the completion of baseline care plans, despite expectations from the MDS Coordinator, DON, and Administrator for timely completion.
The facility failed to provide complete and individualized care plans for residents, leading to deficiencies in addressing ADL needs, dietary preferences, and accurate medical orders. A resident with severe cognitive impairment lacked a care plan for ADL needs, another resident's vegetarian diet was not accommodated, and a third resident's care plan contained outdated information. Staff interviews confirmed the care plans were not reflective of current needs.
A resident with dementia and other conditions was allowed to smoke outside in a nonsmoking facility, due to lack of staff awareness and training. The resident had cigarettes and a lighter, supplied by a family member, and was unsupervised by an untrained Activity Aide. The facility lacked a written nonsmoking policy, and key staff were unaware of the resident's smoking activities.
A resident with a history of stroke and dysphagia was administered the wrong enteral nutritional supplement due to a failure to verify the physician's order. The RN did not check the supplement before administration, and the DON was unaware of the stock issue, highlighting a lack of policy for physician orders.
The facility failed to properly label and store medications, as home medications not in use were found in the medication room. Staff interviews revealed confusion over responsibility for monitoring medication storage, with a CMT and LPN unaware of the presence of these medications. The DON indicated that the charge nurse should oversee medication rooms, but this was not effectively implemented.
A facility failed to ensure timely communication and documentation of critical lab results for a resident with chronic conditions, leading to delayed treatment. Despite multiple attempts, a urine sample was delayed from May 2 to May 7 without proper documentation or physician notification. Critical blood test results collected on June 7 were not communicated promptly, delaying emergency care until June 10. Staff interviews revealed inconsistencies in lab result handling, contributing to the deficiency.
A resident with severe cognitive impairment and a preference for a vegetarian diet was not provided with adequate vegetarian meal options. The facility failed to address the resident's dietary preferences in their care plan, and staff interviews revealed a lack of appropriate vegetarian alternatives, relying instead on the resident's family to supply meals.
A facility failed to resolve a grievance concerning a resident's transfer method. The resident, with severe cognitive impairment, experienced pain from a stand-up lift. Despite a grievance suggesting an evaluation for a Hoyer lift, the facility did not conduct the assessment. The Director of Therapy did not evaluate the resident, and the care plan lacked specific transfer instructions. The resident was discharged without resolution, leading to a deficiency.
The facility did not notify the State LTC Ombudsman of resident transfers and discharges. The Ombudsman had not received a monthly transfer report since March 2024. The Social Services Director, new to the role since April 2024, had not sent the reports, intending to organize first. The Administrator assumed the reports were being sent as before.
A resident with a history of aggression pushed another resident to the ground during an argument over a walker, resulting in a fractured femur. Despite the escalating situation, staff present did not physically intervene to separate the residents. The facility's abuse prevention policy lacked specific guidance on intervention, and many staff had not attended relevant training.
A resident with a history of aggression entered another resident's room and demonstrated physical aggression, but the incident was not reported to the Administrator, physicians, or responsible parties as required by the facility's policy. The lack of immediate reporting and intervention led to a delayed investigation and further incidents of aggression.
A LTC facility failed to document specific behaviors of a resident with dementia, leading to insufficient information for the IDT to determine effective interventions. The resident exhibited aggressive behaviors, including physical aggression towards others. Another resident expressed fear after being pushed down, resulting in a fractured femur, but did not receive adequate psychosocial follow-up. Staff were unsure of the aggressive resident's triggers and interventions, and documentation was inadequate.
Failure to Transcribe and Implement Physician Orders for Medications and Labs
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were accurately transcribed and implemented in residents’ electronic medical records (EMR), resulting in missed medication changes and laboratory testing for two residents. Facility policy required that all physician orders, including those received via telephone, fax, written, verbal, or transcribed orders, be documented in the EMR and that corresponding requisitions be completed for laboratory and diagnostic services. For one resident with anemia, hypertension, seizure disorder, anxiety, depression, and bipolar disorder, a physician progress note directed routine labs including an autoimmune profile, initiation of doxycycline 100 mg twice daily for 10 days, discontinuation of lithium, and a lithium level check. The EMR, however, still showed an active order for lithium carbonate 450 mg twice daily and contained no orders or documentation for doxycycline, routine labs, or a lithium level. The resident reported wanting to stop lithium because it made them feel “funny,” and an LPN later stated they were unaware of the physician’s 4/9/26 orders and would normally review progress notes to add such orders. For another resident with diabetes and depression, a physician progress note ordered routine laboratory studies for further evaluation, but the EMR contained no corresponding lab orders and no documentation that the labs were completed. This resident reported that their physician had ordered lab work but no one had come to draw blood. Staff interviews revealed that one LPN believed the Medical Director’s new orders from 4/9/26 were sent to the DON, who was understood to be responsible for entering new physician orders into the EMR. The DON stated she would review the physician progress notes and give the orders to the charge nurse to implement, and acknowledged she did not know what happened to the orders from the notes or that they had not been followed. The Administrator stated he expected facility policy regarding physician orders to be followed and that this was the first time he had heard about these issues with orders not being followed.
Failure to Provide Adequate Supervision and Safe Transfer Assistance
Penalty
Summary
Staff failed to provide adequate supervision and assistance to prevent accidents for a resident with severe cognitive impairment, limited mobility, and a history of repeated falls. The resident required a Hoyer lift with two staff for all transfers, as documented in the care plan and facility policy. However, one CNA, unaware of the resident's transfer requirements, used a gait belt instead of the Hoyer lift to transfer the resident from bed to wheelchair. This method was not in accordance with the resident's care plan or facility policy, which mandates mechanical lifts and two-person assistance for residents needing such support. Later, another CNA observed the resident sliding out of a wheelchair and, unable to locate a second staff member, used the Hoyer lift alone to transfer the resident back to bed. This action was also contrary to facility policy and training, which require two staff members for Hoyer lift transfers to ensure resident safety. Multiple staff interviews confirmed that all were trained to use two people for Hoyer lift transfers and to wait for assistance if a second person was not immediately available. Following these improper transfers, the resident was found with a hematoma on the back of the head and a swollen leg. The resident was sent to the hospital, where imaging revealed a closed fracture of the proximal left tibia. Documentation and interviews indicated that the improper transfer methods directly preceded the discovery of these injuries, and staff statements confirmed deviations from established transfer protocols.
Failure to Investigate Injury and Notify Family
Penalty
Summary
The facility failed to meet professional service standards by not investigating an injury case for a resident who sustained a right foot fracture. The staff did not notify the resident's family about the change in condition, nor did they fully transcribe or clarify orders from the hospital emergency room. The resident, who had a history of stroke, dementia, unspecified psychosis, and high blood pressure, was found to have an acute non-displaced fracture of the fifth metatarsal bone in the right foot. Despite the hospital's instructions for care, including the use of a boot, ice packs, and elevation, these were not fully implemented or documented in the resident's care plan. The facility's Accident and Incident Investigation Guidelines were not followed, as there was no evidence of a thorough investigation into the cause of the injury. The staff failed to secure witness statements or inspect the environment for causative factors. Additionally, there was confusion among the staff regarding the physician's orders, particularly concerning the taping of the resident's toes, which led to incorrect treatment. The lack of communication and documentation resulted in the resident not receiving the appropriate care and monitoring as prescribed. Interviews with facility staff revealed a lack of understanding and adherence to the facility's policies and procedures. The staff did not notify the family or physician promptly about the resident's condition, and there was a misunderstanding about the facility's ability to handle STAT orders. The administrator acknowledged the need for clarification and education regarding STAT orders and emphasized the importance of notifying families about changes in residents' conditions. The failure to investigate the injury and communicate effectively with the family and physician contributed to the deficiency in care provided to the resident.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with pressure ulcers, as staff did not adhere to physician orders and facility policy. The resident, who had multiple medical conditions including hemiplegia, aphasia, and unhealed pressure ulcers, was observed without the required heel protector boots and dressing on the left heel. The resident's medical record indicated orders for Prevalon boots to be worn at all times while in bed and for a foam dressing to be applied daily to the left heel. However, during an observation, the resident was found with both heels flat on the bed, without the protective boots or dressing, and with a visible black and deep purple spot on the left heel. Interviews with facility staff revealed a lack of awareness and adherence to the updated wound care orders. A CNA confirmed the absence of a dressing and boots, while an LPN admitted to not being aware of the change in orders to apply a dressing, having only used skin prep on the heel. The LPN acknowledged that all orders should be verified prior to treatment, but had not done so since the order change. This oversight resulted in the resident not receiving the prescribed wound care, which was confirmed by the observation of the resident's heel condition. The facility's administrator stated that nursing staff are expected to review all orders before administering treatments and medications, and to check progress notes for continuity of care. Despite these expectations, the failure to follow the updated wound care orders led to the deficiency, as the resident did not receive the necessary treatment to promote healing of the pressure ulcer.
Failure to Segregate Resident Funds from Operating Account
Penalty
Summary
The facility failed to ensure that resident funds were placed in an account separate from the facility's operating account, affecting 26 residents. The Accounts Receivable Aging Report revealed that significant amounts of personal funds were held in the facility's operating account, totaling $164,763.34. During email correspondence, the Business Office Manager acknowledged that some of these funds were valid credits and should be refunded, while others required further investigation to verify their validity. The Administrator admitted that the facility was unaware of these credit balances in the Accounts Receivable Account.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond to protect resident funds. A review of the facility's Resident Trust Bank Statements from June 2024 to November 2024 showed an average monthly balance of $19,158.19. However, the Accounts Receivable Aging Report dated November 22, 2024, indicated that the facility held a balance of resident funds amounting to $164,763.34. Despite this, the facility only had an approved bond of $30,000, which was insufficient by $246,000. During an interview, the Administrator admitted that the facility was unaware of the credit balances in the Accounts Receivable Account and stated that the credits would be corrected or the bond increased.
Failure to Prevent Accidents Due to Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for two residents, resulting in significant injuries and unsafe transfer practices. In the first incident, a resident with multiple impairments, including debility, dementia, diabetes, and impaired mobility, was dependent for all bed mobility and required maximum assistance. During perineal care, a CNA attempted to move the resident alone on a low air loss mattress, despite the resident's requests for a second staff member and the increased risk associated with the mattress type. The CNA did not secure the bed wheels and failed to obtain additional help, leading to the resident falling from the raised bed and sustaining three spinal compression fractures, a tooth avulsion, and facial contusions. Interviews and documentation revealed that staff were unclear about the resident's required level of assistance for bed mobility, and this information was not consistently documented in the care plan or Kardex prior to the incident. In the second incident, another resident, who was severely cognitively impaired and required maximal assistance for bed mobility and transfers, was observed being transferred by two CNAs using improper gait belt technique. The resident was unable to support their own weight or respond to directions, yet the CNAs placed a loose gait belt around the resident's waist and lifted the resident by the shoulders and the back of the pants, rather than using the gait belt as required by facility policy. The resident's feet did not touch the floor during the transfer, and the resident did not participate in the movement. Both CNAs admitted to not following safe gait belt practices, and one CNA was unsure of the resident's transfer status, indicating a lack of clear communication and training regarding safe transfer procedures. Interviews with staff and administrators confirmed that there was confusion and inconsistency in how transfer status and required assistance levels were communicated and documented. Therapy staff, nursing staff, and CNAs provided conflicting accounts of how transfer status was determined and relayed, and there was no clear documentation specifying whether one or two staff were required for certain residents. The facility's policies required individualized, resident-centered approaches to safety, but these were not consistently implemented, leading to unsafe practices and preventable accidents.
Failure to Provide Timely EMR Access to Surveyor and Hospice Providers
Penalty
Summary
The facility failed to provide timely access to its electronic medical records (EMR) to both a state Surveyor and hospice care providers, resulting in a deficiency related to safeguarding and maintaining resident-identifiable information in accordance with professional standards. On the day of the survey, the Surveyor arrived at 8:00 A.M. and requested EMR access, but was not provided with functional access before the end of the workday. Multiple attempts were made by the Director of Nursing (DON) to provide passwords, but these either did not work or only allowed partial access. The issue was not resolved before the Surveyor had to leave, and the Administrator acknowledged the lack of access but did not provide a solution during the surveyor's visit. For a resident receiving hospice care, the facility also failed to provide the hospice team with access to the resident's EMR, despite the resident's documented consent and a contract between the facility and the hospice provider. The hospice nurse and director reported repeated refusals by the Administrator to release the resident's medical records, either electronically or in printed form, even after multiple requests and the provision of necessary documentation. The Administrator required the hospice team to attend care plan meetings before granting access and refused to send records to the email address provided by the hospice nurse, citing concerns about the address not being specific to the company. The hospice team was unable to access the resident's EMR onsite or offsite and could only obtain limited information by requesting printed records from facility staff, which was also restricted by the Administrator's instructions. The lack of access to the EMR affected the hospice team's ability to coordinate care, as they could not verify medication orders, treatments, or make necessary changes to the plan of care. The resident in question had severe cognitive deficits, kidney failure, and dementia, and was actively receiving hospice services at the time of the deficiency.
Failure to Monitor and Report Changes in Resident Conditions
Penalty
Summary
The facility failed to thoroughly and accurately assess, document, and notify the physician of a change in condition for two residents and one closed record. Resident #44, diagnosed with congestive heart failure and a history of fluid retention, experienced weight gain and respiratory changes that were not monitored or reported to the physician. This oversight led to the resident being transported to the hospital and administered intravenous Lasix. Resident #306 exhibited symptoms of confusion and an inability to use a motorized wheelchair. Despite receiving orders for lab work, critical lab results were not communicated to the physician until several days later, during which the resident's condition worsened, including an inability to use utensils and increased confusion. The delay in notifying the physician resulted in the resident being transported to the hospital with acute kidney failure and a urinary tract infection. Additionally, the facility failed to order a urinalysis for Resident #36, who later went to the hospital with a kidney infection. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not adhered to, leading to inadequate monitoring and delayed medical intervention for the affected residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care for a resident who was readmitted with a Stage II pressure ulcer on the coccyx, which subsequently worsened to a Stage III pressure injury. Upon readmission, the facility did not conduct necessary wound measurements, transcribe hospice wound care orders, or notify the physician about the wound. This lack of action led to the resident developing additional wounds and the existing wound increasing in severity, with slough present, indicating a progression to a Stage III pressure injury. The resident, who had moderate cognitive impairment and required substantial assistance with daily activities, was at high risk for developing pressure injuries due to conditions such as heart failure, diabetes, and paralysis. Despite these risk factors, the facility's staff did not follow the established protocol for wound care. The resident's care plan included interventions for skin integrity, but these were not effectively implemented. The resident's wounds were not documented in the facility's wound report, and there was no record of wound care orders or assessments in the medical records. Observations revealed that the resident had multiple open wounds on the buttocks, which were not properly treated or reported by the staff. The CNA and LPN involved did not ensure that the wounds were assessed or that the physician was notified. The facility's Director of Nursing was unaware of the resident's condition until several days after readmission, highlighting a breakdown in communication and documentation. The hospice provider had given verbal wound care orders, but these were not transcribed into the medical records, leading to a delay in treatment.
Facility Fails to Maintain Food Safety and Cleanliness Standards
Penalty
Summary
The facility failed to maintain proper time/temperature controls for safety food, which is essential to limit the growth of pathogens and prevent foodborne illnesses. Observations revealed that the walk-in cooler door was repeatedly propped open, causing the internal temperature to rise above the safe threshold of 41 degrees Fahrenheit. Several food items, including pureed meat, ham, and cottage cheese, were found to be stored at temperatures exceeding this limit. Additionally, the facility lacked thermometers for staff to monitor food temperatures, and the walk-in freezer's external thermometer indicated a temperature of 10 degrees Fahrenheit, although the food remained frozen solid. The facility's dishwashing equipment was not in working order, with the main kitchen's dishwasher out of service since May and the SNF dish room's machine in poor condition. Staff were observed washing dishes by hand in a three-compartment sink without proper sanitization due to a lack of a functioning sanitizer sink. This inadequate dishwashing process posed a risk of cross-contamination. Furthermore, the handwash sinks in the first-floor kitchenette and SNF dish room were not operational, preventing staff from washing their hands and increasing the potential for cross-contamination. The overall cleanliness of the kitchen and kitchenette areas was substandard, with food scraps, grease, and dust accumulating on floors, walls, and equipment. Open food items were not properly labeled, dated, or sealed, and scoops were improperly stored, increasing the risk of cross-contamination. These deficiencies had the potential to affect all residents who consumed food prepared in the facility, as the census was 53 at the time of the survey.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program, which is a requirement under the Affordable Care Act of 2010. This deficiency had the potential to affect all 53 residents in the facility. The Administrator, who started in March 2024, acknowledged during an interview that while the facility possesses the CMS QAPI at a glance guide, no facility-specific QAPI plan has been initiated. The Administrator was unaware of any existing plan prior to her tenure and cited several emergency issues that have prevented her from implementing a corrective plan. Although a QAPI committee meeting was planned for July 2024, it was not organized.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. Lighting issues were prevalent, with the spa room and men's restroom on the first floor having inadequate lighting. The dining room had chipped paint and duct tape on the floor, and several resident rooms exhibited various environmental concerns, such as torn drywall, unfinished ceilings, and missing privacy curtains. Additionally, strong odors of urine were noted in some rooms, indicating a lack of cleanliness and maintenance. Interviews with staff revealed a lack of awareness and communication regarding maintenance issues. A CNA reported that the lighting problems had been ongoing and reported to maintenance, while an LPN was unaware of the non-functional restroom light and did not know the proper procedure for reporting maintenance issues. The DON and Administrator were also unaware of the extent of the deficiencies, including missing privacy curtains, strong urine odors, and the need for repairs and painting in several areas. The Housekeeping Supervisor, who had recently assumed the position, acknowledged the strong urine odor in specific rooms and indicated that a deep cleaning program was underway. However, the report highlights a systemic issue with communication and maintenance processes, as staff were unclear about reporting procedures, and significant environmental concerns had persisted without resolution.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data within the required 7 days after completing a resident's assessment for seven residents. The Minimum Data Set (MDS) assessments for these residents were either showing as 'in progress' or 'ready to export' but had not been transmitted. This issue was identified during a review of the facility's compliance with the MDS encoding and transmission requirements, as outlined in the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual. The MDS Coordinator, who had been in the role since April, acknowledged that there were alerts in the electronic medical record system to notify when an MDS was due. However, she faced challenges with the system, which was different from what she was accustomed to, and encountered glitches that delayed the transmission process. The Coordinator had to manually find each resident's MDS for transmission, which was time-consuming. She also mentioned that the residents who did not have transmitted MDS assessments were from before her tenure, and she was not aware of any issues with transmitting the MDS when she started. Interviews with the Director of Nursing (DON) and the Administrator revealed that there were expectations for the MDS to be accurate and submitted timely, but they were not aware of the transmission issues. The MDS Coordinator was able to pull up validation reports to check if assessments were rejected or accepted, and most were rejected. The facility's electronic medical record system indicated 'exported' or 'export ready,' but the Coordinator had to correlate this information manually. The deficiency was highlighted by the failure to transmit the MDS assessments within the required timeframe, impacting the facility's compliance with federal and state regulations.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for two residents requiring such services. Resident #107, who has diagnoses including stroke, end-stage renal disease, and diabetes, was observed to have no documented communication between the facility staff and the dialysis center. The resident's care plan indicated dialysis treatments on specific days, but there were no physician orders to assess or monitor the resident before or after dialysis treatments. Additionally, there was no policy in place to address assessments, monitoring, and communication with dialysis centers. Resident #106, who is cognitively intact and has diagnoses including heart failure, diabetes, cerebral palsy, and end-stage renal disease, also lacked proper documentation and orders related to dialysis care. The resident's care plan noted hemodialysis three times a week, but there were no orders specifying the days or location of dialysis. The facility administrator acknowledged the absence of necessary orders and policies, indicating a lack of documentation for communication between the dialysis center and the facility.
Failure to Conduct Risk-Benefit Assessments for Siderail Use
Penalty
Summary
The facility failed to conduct comprehensive risk-benefit assessments for the use of siderails for seven residents, which is a critical step in ensuring resident safety. The absence of these assessments means that the facility did not evaluate the potential risks of entrapment or injury against the benefits of siderail use for each resident. This oversight was observed in residents with various medical conditions, including dementia, history of falls, hemiplegia, and severe cognitive impairment, all of whom had siderails installed without documented assessments. For instance, Resident #43, diagnosed with dementia and a history of falls, had a quarter-length siderail attached to their bed without a comprehensive risk-benefit assessment or a care plan. Similarly, Resident #20, with multiple diagnoses including dementia and hemiplegia, had bilateral U-rails on their bed without any orders or assessments documented. Observations revealed that these siderails were not used by the resident, indicating a lack of individualized assessment and planning. Interviews with facility staff, including the Administrator, Director of Therapy Services, and Director of Nursing, revealed a lack of awareness and systems in place for assessing and maintaining siderails. The Director of Therapy Services admitted to not completing specific siderail assessments, and the Director of Nursing was unaware of any systems for siderail assessment and maintenance. The Administrator acknowledged the absence of a monitoring system and the need for assessments prior to siderail use, highlighting a systemic issue in the facility's approach to siderail safety.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the facility's payroll-based journal (PBJ) staffing report for the second quarter of 2024, covering January 1 to March 31. The report highlighted multiple dates where no RN hours were recorded, triggering a one-star staffing rating and indicating a lack of RN coverage on specific days. During an interview, the administrator suggested that the previous Director of Nursing (DON) might not have properly recorded their hours when working as an RN, or they may not have known how to update the PBJ file, leading to the absence of recorded RN hours.
Improper Waste Containment in Kitchen and Dish Room
Penalty
Summary
The facility failed to properly contain waste and refuse, leading to the potential harboring and feeding of rodents and pests. Observations on multiple occasions revealed that trash cans in the main kitchen and skilled nursing facility (SNF) dish room were uncovered and overflowing with trash, including cans. Flies were observed in the kitchen, particularly in areas where food was prepared, and an insect light was found to be turned off due to having the wrong bulbs. During an interview, the Administrator and Assistant Dietary Manager acknowledged that trash cans should be covered when not in use and that the uncovered trash cans contributed to the presence of flies. The facility census at the time was 53.
Failure to Document Hospice Orders and Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to document hospice orders and develop a comprehensive written plan of care for a resident receiving hospice services. The deficiency was identified for one of three residents on hospice care, specifically Resident #9. The facility's policy mandates that hospice services be documented and integrated into the resident's overall plan of care, but this was not adhered to. The resident was admitted to hospice services, but the necessary hospice orders and wound care treatments were not documented in the electronic physician order sheet (ePOS) until several days later. Additionally, the resident's care plan did not reflect the hospice services being provided. Interviews with the Director of Nursing and the hospice manager revealed a lack of communication and coordination between the facility and the hospice provider. The facility did not have a hospice liaison, and the social worker was expected to coordinate with hospice providers. Despite the hospice Registered Nurse documenting skin care orders, these were not communicated effectively to the facility staff, and the hospice plan of care was not integrated into the facility's care plan. This lack of documentation and coordination led to the deficiency noted by the surveyors.
Failure to Offer Influenza Vaccination
Penalty
Summary
The facility failed to offer and provide the influenza vaccine to two residents, as per the CDC guidelines. Resident #44, who had severe cognitive impairment and diagnoses including heart failure, dementia, and seizure disorder, did not receive the influenza vaccine. The medical record indicated that the vaccine was offered and declined, but there was no documentation of education regarding the benefits and potential side effects of the vaccine, nor was there a documented refusal. Similarly, Resident #1, who was cognitively intact and had diagnoses including heart failure, dementia, weakness, and kidney disease, also did not receive the influenza vaccine. The record showed the vaccine was offered and declined, yet lacked documentation of education and refusal. During an interview, the infection control nurse acknowledged that neither resident received the influenza vaccination and that they were not offered the declination form. The nurse had conducted an audit and found that several residents did not receive the influenza vaccination or the option to decline it. The facility's policy was to offer the vaccine from October through March, with forms sent to residents and families around September. The nurse, who had been at the facility since the last influenza season, assumed all residents had been offered the vaccinations, highlighting a lapse in the facility's vaccination program.
Failure to Provide SNF-ABN Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents who remained in the facility after their Medicare Part A services were discharged. This deficiency was identified for two residents, one whose last covered day of Medicare Part A service was on March 18, 2024, and another on May 30, 2024. In both cases, the facility initiated the discharge from Medicare Part A services before the benefit days were exhausted, yet did not provide the necessary SNF-ABN form CMS-10055 or an alternative denial letter to the residents or their legal representatives. Interviews with facility staff revealed a lack of awareness and responsibility regarding the issuance of SNF-ABNs. The Social Service Director (SSD) acknowledged handling only the Notice of Medicare Provider Non-Coverage (NOMNC) and was not aware of SNF-ABNs being distributed in the facility. The Minimum Data Set (MDS) Coordinator, who also dealt with Medicare A discharges, confirmed that SNF-ABNs should be provided but was unaware of their distribution. The facility Administrator was also unaware that staff were not providing the SNF-ABNs, despite knowing they should be issued.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to deficiencies in the documentation of their medical conditions. For one resident, the admission and quarterly MDS assessments inaccurately listed Alzheimer's disease as the only active diagnosis, despite the resident having multiple other diagnoses, including vascular dementia, psychotic disturbance, mood disturbance, anxiety, and hypertension. The staff also failed to mark the section indicating no other active diagnoses within the last seven days, which further contributed to the inaccuracy of the resident's assessment. Another resident with end-stage renal disease, who was receiving hemodialysis three times a week, had an incomplete quarterly MDS assessment. The section for Special Treatments and Programs, which should have included dialysis, was left blank. This omission failed to accurately reflect the resident's treatment needs and care plan focus, which included checking the dialysis catheter site every shift. The facility's administrator acknowledged the expectation for MDS assessments to accurately represent the residents' conditions.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident, identified as Resident #305, within the required timeframe. The facility's policy mandates that a preliminary care plan be developed within 24 hours of admission to address the resident's immediate care needs. However, upon review, it was found that no baseline care plan was documented for Resident #305, who was admitted on an unspecified date. The resident had several physician's orders, including hospice evaluation, topical antibiotic application, nutritional supplements, and wound care treatments, which were not incorporated into a baseline care plan. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of baseline care plans. The Minimum Data Set (MDS) Coordinator acknowledged that the baseline care plan for Resident #305 was not completed and mentioned that either the admitting nurse or another nurse could have done it. The Director of Nursing (DON) and the Administrator both expected the baseline care plan to be completed within 24-48 hours of admission. Despite these expectations, the necessary care plan was not developed, indicating a lapse in the facility's adherence to its own policies and procedures.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #28, the care plan did not address the resident's Activities of Daily Living (ADL) needs, despite the resident having severe cognitive impairment, being a fall risk, and requiring assistance with most activities. Observations showed the resident attempting to stand from a wheelchair unsafely, and interviews with staff confirmed the resident's need for reminders, cues, and assistance with transfers and personal care. Resident #44's care plan did not address dietary preferences, even though the resident had severe cognitive impairment and practiced a vegetarian lifestyle. The resident expressed dissatisfaction with the facility's food options, indicating that staff did not take their dietary preferences seriously. Progress notes indicated that the resident's dietary preferences were known to the facility, yet they were not reflected in the care plan. For Resident #106, the care plan included outdated and inaccurate information, such as a fluid restriction and dietary orders that were not present in the current physician's orders. Additionally, the care plan mentioned smoking supervision, although the facility was smoke-free. Interviews with staff highlighted the expectation that care plans should be up-to-date and reflect the resident's current needs, which was not the case for these residents.
Failure to Enforce Nonsmoking Policy Leads to Resident Smoking Incident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident who was allowed to smoke during an outside activity, despite the facility being a nonsmoking environment. The resident, who has diagnoses including dementia, anxiety, impaired balance, and major depressive disorder, was observed smoking a cigarette outside with other residents present. The resident had a lighter and a package of cigarettes in their possession, which were supplied by a family member. The Activity Aide present was unaware of the facility's nonsmoking status and had not received training on supervising a smoking resident. No ashtray was available, and the nearest fire extinguisher was located inside the facility. The facility's staff, including the Registered Nurse, Social Worker Director, Director of Nursing, and Administrator, were not fully aware of the resident's smoking activities or the existence of a smoking order. The facility had transitioned to a nonsmoking status earlier in the year, but there was no written nonsmoking policy, only verbal communication and information in the resident handbook. The Administrator and Director of Nursing were not informed of the resident's smoking activities until after the incident occurred, indicating a lack of communication and enforcement of the nonsmoking policy.
Administration of Incorrect Enteral Nutritional Supplement
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as evidenced by the administration of the wrong enteral nutritional supplement to a resident with a feeding tube. The resident, who had a medical history including stroke, dysphagia, and hemiplegia affecting the right side, had a physician's order for Glucerna 1.5 Cal oral liquid nutritional supplement to be administered via gastrostomy tube if less than 50% of a meal was consumed. However, during an observation, a registered nurse administered Glucerna 1.2 instead of the prescribed Glucerna 1.5. The registered nurse admitted to not verifying the nutritional supplement with the physician's order before administration. Additionally, the Director of Nursing was unaware that the facility did not have Glucerna 1.5 in stock and acknowledged that a physician's order should be obtained before substituting a nutritional supplement. The facility's lack of a policy and procedure for physician orders contributed to this oversight, as confirmed by the Administrator during an interview.
Deficiency in Medication Storage Practices
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an observation of the 200-unit medication room, it was found that two separate gallon Ziploc bags contained home medications for residents that were not in use at the facility. These medications were not from the facility pharmacy and included various drugs such as Lasix, carbidopa/levodopa, Farxiga, Metoprolol, and others. The facility's pharmaceutical storage policy mandates that drugs should be stored in a safe, sanitary, and orderly manner, and only those prescribed for individual residents should be kept on the premises. However, the home medications were still present in the medication room despite the residents having been at the facility for several months. Interviews with facility staff revealed a lack of clarity and responsibility regarding the monitoring of medication rooms for unused or home medications. A Certified Medication Technician (CMT) acknowledged that home medications should no longer be in the medication room, while a Licensed Practical Nurse (LPN) admitted to not knowing who was responsible for monitoring the medication room. The Director of Nursing (DON) stated that the charge nurse should monitor the medication rooms for expired and home medications, and that home medications should be returned to the family once the facility pharmacy delivers the ordered medications. This lack of oversight and adherence to policy led to the deficiency in medication storage practices.
Failure to Timely Communicate and Document Critical Lab Results
Penalty
Summary
The facility failed to ensure timely communication and documentation of critical laboratory results for a resident, leading to a delay in treatment. The resident, who had a history of hypertension, chronic kidney disease, and other conditions, was admitted with symptoms that warranted a urinalysis (UA) with culture sensitivity (CS). Despite multiple attempts to obtain a urine sample from the resident, there was a significant delay from May 2 to May 7, during which no documentation was made regarding the inability to collect the sample or notify the physician. The urine sample was eventually collected on May 22, and the results, indicating an abnormal E. coli infection, were not reported until May 27, with treatment starting on May 30. Additionally, the facility did not manage the communication of critical blood test results effectively. On June 6, the resident exhibited increased confusion and other symptoms, prompting a request for lab work. The blood samples were collected on June 7, and the results, which included critical low glucose and high BUN levels, were reported on the same day. However, there was a failure in ensuring these critical results were communicated to the physician in a timely manner, as the resident was not sent to the emergency room until June 10, after the physician was finally notified of the critical lab results. Interviews with facility staff revealed inconsistencies in the process of receiving and handling lab results. There were multiple methods for receiving lab results, including fax, email, and an online portal, but there was no clear protocol ensuring that critical results were promptly communicated to the appropriate medical personnel. The lack of a formal process for timely lab result management and the absence of documentation regarding the delays contributed to the deficiency in care provided to the resident.
Failure to Accommodate Vegetarian Dietary Preferences
Penalty
Summary
The facility failed to provide a resident with a nourishing, well-balanced diet that accommodated their vegetarian preferences. The resident, who had severe cognitive impairment and required supervision for certain activities, expressed dissatisfaction with the food options provided, stating that they did not eat meat and had been given limited vegetarian alternatives, such as cheese sandwiches and occasionally fish. The resident's care plan did not address their dietary preferences, and the facility relied on the resident's family to bring in vegetarian meals. Interviews with staff, including a Certified Nurse Aide, a Registered Dietician, and a Licensed Practical Nurse, revealed awareness of the resident's vegetarian diet preference but indicated that the facility did not offer adequate vegetarian options. The resident was often served only side dishes or given extra vegetables to replace meat options. The Director of Nursing incorrectly stated that no residents had dietary preferences, while the Administrator acknowledged that alternate choices should be offered for residents with specific dietary preferences.
Failure to Resolve Grievance Regarding Resident Transfer Method
Penalty
Summary
The facility failed to adhere to its grievance policy concerning a resident's transfer method, leading to a deficiency. A family member of the resident, who had severe cognitive impairment and required substantial assistance for mobility, filed a grievance regarding the use of a stand-up lift, which caused the resident pain. The grievance suggested that the therapy department evaluate the resident to determine the appropriate transfer device, such as a Hoyer lift, which was believed to be more suitable given the resident's condition. Despite the grievance being logged and a resolution date being noted, the facility did not conduct the necessary evaluation. Interviews revealed that the Director of Therapy (DOT) did not evaluate the resident for the Hoyer lift, as initially recommended. The DOT believed the resident was too shaky for the Hoyer lift and too weak for the sit-to-stand lift, but this assessment was not documented or communicated to the family. The resident's care plan did not reflect any specific transfer method, and the resident was discharged to the hospital without the issue being resolved. The lack of follow-up and communication regarding the grievance led to confusion among staff, with the Social Worker assuming the evaluation had been completed based on the DOT's verbal feedback. The facility's failure to evaluate the resident and communicate the findings to the family member resulted in a deficiency, as the grievance process was not properly executed according to the facility's policy.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify a representative of the State Long-Term Care Ombudsman of resident transfers and discharges, as required. The facility had a census of 53 residents. During an interview, the Ombudsman stated that they had not received a monthly transfer report from the facility since March 2024. The Social Services Director, who assumed the position in April 2024, acknowledged not sending the monthly transfers to the Ombudsman, citing a need to acclimate to the role and organize binders. The Administrator believed that the Social Services Director was responsible for notifying the Ombudsman and that the reports were being sent, as they had been previously sent by email.
Failure to Intervene in Resident Altercation Leads to Injury
Penalty
Summary
The facility failed to protect a resident from abuse when staff did not appropriately intervene during an altercation between two residents. Resident #1, who has a history of verbal and physical aggression and is diagnosed with Alzheimer's disease, dementia, and anxiety, engaged in an argument with Resident #3 over a walker. Despite the escalating situation, staff did not physically intervene to separate the residents, resulting in Resident #1 pushing Resident #3 to the ground, causing a fractured femur. The facility's abuse prevention policy emphasizes the importance of protecting residents from abuse and neglect, yet it lacked specific guidance on how staff should intervene in situations where abuse is likely to occur. During the incident, both a Certified Nurse Aide (CNA) and a Certified Medication Technician (CMT) were present but did not take physical action to separate the residents. The CNA attempted verbal redirection, but Resident #1's aggression escalated, leading to the physical altercation. Interviews with staff revealed that Resident #1 is known to become agitated and aggressive, particularly in the late afternoon, and requires redirection to prevent such behaviors. However, staff failed to anticipate and manage the resident's aggression effectively. The facility's training records showed that a significant number of staff, including CMT E, had not attended in-service training on managing resident behaviors, which may have contributed to the inadequate response during the incident.
Failure to Report and Address Resident Aggression
Penalty
Summary
The facility staff failed to adhere to the facility's policy of immediately notifying the Administrator of a physical altercation between two residents, which resulted in a delayed investigation and implementation of interventions. Resident #1, who has a history of moderate cognitive impairment and aggressive behavior, entered Resident #4's room and demonstrated physical aggression. Despite the incident, the staff did not report it to the Administrator, the residents' physicians, or their responsible parties, as required by the facility's Abuse Prevention policy. Resident #1, diagnosed with Alzheimer's disease, dementia, and anxiety, was known for verbal aggression and had a care plan in place to monitor and manage such behaviors. However, the staff failed to document the physical aggression incident in Resident #1's progress notes accurately, and there was no indication that the resident's physician or responsible party was notified. Similarly, Resident #4, who has severe cognitive impairment and requires substantial assistance, did not have any documentation in their medical record regarding the incident. Interviews with various staff members revealed that Resident #1's aggressive behavior was known, yet no increased monitoring or immediate protective measures were implemented following the incident. The Director of Nursing and the Administrator were not informed of the altercation until the following day, which allowed Resident #1 to re-enter Resident #4's room and exhibit further aggression. The lack of immediate reporting and intervention highlights a significant deficiency in the facility's handling of resident safety and abuse prevention protocols.
Inadequate Documentation and Psychosocial Support in LTC Facility
Penalty
Summary
The facility failed to ensure consistent documentation and detailed reporting of specific behaviors exhibited by a resident with dementia, leading to insufficient information for the interdisciplinary team (IDT) to determine effective non-pharmacological interventions. The resident, who had a history of Alzheimer's disease, dementia, and anxiety, displayed aggressive behaviors, including physical aggression towards other residents. Despite multiple incidents of aggression, the nursing staff's documentation lacked specific details about the behaviors, such as onset, frequency, and precipitating factors, which are crucial for developing appropriate interventions. Additionally, the facility did not provide adequate psychosocial follow-up for another resident who expressed fearfulness after being pushed down by the aggressive resident, resulting in a fractured femur. The social services director (SSD) was not informed of the ongoing behaviors or the incident's impact on the affected resident's mental well-being. The SSD's evaluations did not reflect the resident's fearfulness or the traumatic nature of the incident, and the care plan failed to address the resident's expressed fear and need for support. Interviews with staff revealed a lack of awareness and understanding of the aggressive resident's triggers and effective interventions. Staff reported feeling unsure of how to manage the resident's behaviors and noted that the documentation of these behaviors was inadequate. The facility's administration acknowledged the need for more descriptive behavior charting to identify triggers and develop resident-specific interventions, but this was not implemented at the time of the deficiency.
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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