Ignite Medical Resort Carondelet Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 621 Carondelet Drive, Kansas City, Missouri 64114
- CMS Provider Number
- 265303
- Inspections on file
- 35
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Ignite Medical Resort Carondelet Llc during CMS and state inspections, most recent first.
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 hemiplegia, aphasia, unsteadiness, ADL deficits, and fall risk had a care plan indicating a desire to remain for LTC, but the facility issued a NOMNC ending Medicare coverage without completing required provider sections and without updating the care plan to reflect an active discharge plan. The DCT documented functional barriers such as stairs and bathing, sent referrals to other facilities, and acknowledged not asking the resident about specific transfer preferences or consistently documenting discharge-planning discussions. The Administrator and DCT told the resident they could not stay, actively sought alternative placement, and discussed possible return to a motel, while no formal discharge notice was issued and the existing care plan still showed an initial plan for LTC.
The facility failed to provide required medically-related social services and discharge planning for a cognitively intact resident with hemiplegia, aphasia, ADL deficits, and fall risk. Although policy required Social Services and the IDT to assess discharge potential, arrange outside services, and assist with community placement options, documentation from the Director of Care Transitions showed no referrals to outside entities or help identifying community placements, despite known barriers such as stairs and bathing. The resident reported being told they could not stay, was unsure whether they were being sent to LTC, housing, or an ALF, and stated they had not received information about outside agency assistance. The DCT and Administrator focused on referrals to other facilities, did not provide other community resource referrals, did not obtain the resident’s transfer preferences, and acknowledged that a discharge notice had not been issued, resulting in a lack of planning for potential community services needed for a successful discharge.
Surveyors found multiple environmental and maintenance deficiencies affecting at least 15 residents, including climate control units in several rooms containing debris such as personal items and medication cups, missing or heavily soiled grates, and significant dust and cobweb buildup. Restroom ceiling vent covers in several rooms were loose or missing, a restroom handrail used by a resident was repeatedly observed to be not firmly attached to the wall, and a wall guard in another room was peeling away with protruding screws. The Maintenance Director reported that units should be checked monthly, acknowledged prior checks of some vents, was unaware of the loose wall guard, and believed nursing and housekeeping staff typically entered such issues into the TELS work order system.
Dust Buildup on Vents and Resident Room Fans: The facility failed to keep ceiling vents in a shower room and tabletop fans in multiple resident rooms free from heavy dust buildup. During observation with the FM Director, heavy dust was seen on two ceiling vents and on fans in several rooms, and the Director said a cleaning schedule for the vents had not yet been developed. Two cognitively intact residents stated their fans were cleaned only every now and then or had not been cleaned in a while.
A facility failed to honor food preferences and provide alternative meal choices for residents who ate in their rooms. A resident with dysphagia and weakness reported that staff did not let him/her choose items, served cold food, and did not offer substitutes; observations showed missing items from the meal ticket and blank preference sections. Two other residents also said they were not asked what they wanted, and observations found no alternative menus available in rooms or the dining room despite staff stating that alternatives were available.
Kitchen and dining area sanitation and maintenance were deficient. Observations showed dust on vents and ceiling lights, an open flour bin door, an open bag of breadcrumbs, holes in the wall, loose metal trim, no drain cover in the dish machine room, and a large unsealed hole with debris and a black substance on piping under the prewash sink. The dining room floor also had dried residue and a fresh spill over multiple observations, and the Executive Chef stated the dining room should be swept and mopped after every meal.
Infection Control and EBP Failures During Resident Care: Staff were observed providing care to residents on EBP without consistent gown use, proper hand hygiene, or correct glove changes during dirty-to-clean tasks. A resident with a feeding tube and another with wounds and urinary devices were cared for without the required PPE, and a resident with a suprapubic catheter had a drainage bag dragging on the floor while direct care was provided without the expected gown, gloves, and mask.
Absent Negative Airflow in Multiple Resident Room Restrooms: Surveyors observed that multiple resident room restrooms did not have negative airflow when tested with tissue paper at the ceiling vents; the paper fell instead of being drawn to the vent. The deficiency affected restrooms in several resident rooms, and the Facility Maintenance Director stated he/she had not checked for negative airflow since starting and had not been told to check it in resident rooms.
A resident with adult failure to thrive and intact cognition repeatedly refused scheduled evening showers, stating a preference for morning bathing, yet staff continued to follow a room-based evening shower schedule without documenting nursing follow-up, education, or care plan interventions to adjust bathing times or address the refusals. Over the same period, another resident with dementia, significant ADL and mobility assistance needs, and a history of falls was repeatedly observed in bed or in a wheelchair with the call light placed behind the nightstand and out of reach, despite a care plan and facility policy requiring staff to keep call lights accessible and to encourage and educate the resident on their use.
Insulin was administered to two residents with DM without wiping the insulin pen septum with alcohol before attaching the needle. An LPN was observed giving Humalog to one resident and Novolog and Lantus to another resident without cleaning the pen septum first, and both the LPN and CNO stated the pen should be wiped with alcohol before needle attachment.
A resident with severe vision loss, severe cognitive impairment, total dependence for ADLs/transfers, and pressure injury risk did not have an adaptive call light available and the call light was repeatedly left out of reach or tied to the bed frame. The resident also had an order for Prevalon boots to be worn in bed, but observations showed the boots were not applied during multiple checks. Staff interviews showed uncertainty about the resident’s specific device and boot requirements despite care plan interventions and physician orders.
Lack of Physician Orders for CPAP Use: A resident with OSA, acute respiratory failure, SOB, HF, and hypoxemia was documented by staff as using a CPAP and was observed with the device at the bedside, but the chart had no physician order for CPAP use and no CPAP-related care plan or MDS documentation before the order appeared. Staff interviews confirmed the resident wore the CPAP nightly and that nursing staff were responsible for it, while leadership stated an order should have been in place.
Incomplete dialysis access monitoring and care planning: A resident with ESRD and dependence on dialysis had both a fistula and a CVC, but the care plan and MD orders did not clearly identify the access site or specify daily thrill and bruit checks. Staff described only visual checks for infection, bleeding, or wet/dirty dressings, and monitoring was not consistently performed or documented. During observation, the resident had bruising and puncture wounds at the fistula site and tubing from the CVC covered with a dressing.
A resident with poor dentition and cracked, jagged teeth experienced delayed dental follow-up despite existing dental referral orders and a care plan for oral health monitoring. The record lacked documentation of follow-up dental appointments, dental recommendations, or nursing assessments for ongoing mouth pain, and the resident later developed a dental abscess and reported difficulty chewing, drinking, and pain in the gums, tongue, and jaw. Staff interviews confirmed missing dental documentation and lack of awareness of the resident’s ongoing oral pain.
The facility failed to maintain a comfortable environment, with room temperatures exceeding policy limits, affecting residents' comfort and safety. The cooling system was inadequate, and staff did not consistently report or address the issue, leading to discomfort among residents.
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.
Failure to Develop and Document Appropriate Discharge Plan After Issuing NOMNC
Penalty
Summary
Surveyors identified a failure to develop an appropriate, person-centered discharge plan for a resident when the facility issued a Notice of Medicare Non-Coverage (NOMNC) without completing required elements and without a clear, documented discharge plan. The resident had hemiplegia, aphasia, unsteadiness on feet, ADL deficits, impaired cognitive function, and was at risk for falls. The resident’s care plan documented a wish to remain in the facility for LTC, with goals to evaluate motivation to return to the community and address limitations and needs for maximum independence. Despite this, the facility’s Director of Care Transitions (DCT) documented that there were no environmental barriers impacting discharge, that stairs and bathing were functional/ADL barriers, and that there were no remaining medical education needs, but the care plan was not updated to reflect an active discharge plan. The NOMNC given to the resident stated that Medicare coverage would end on a specified date, but the sections to be completed by the provider (notice delivered by, call date/time, contact person, mailing date to representative, provider signature/title/date) were left blank when given to the resident. The resident reported not receiving a discharge notice but being told by the Administrator and DCT that they could not stay and needed to find another place to go. The resident stated they liked the facility, did not want to move again, wanted to remain in a safe place with shelter, food, showers, and care, and was unsure whether the proposed new placement was LTC or an ALF. The resident also reported that prior medication issues had been resolved and that they did not want to be forced out for expressing anger. Interviews with the DCT and Administrator showed that the facility was actively seeking other placements and intended to move forward with a transfer, without a documented plan for the resident to remain in the facility. The DCT acknowledged sending referrals to other facilities based on the resident’s consent but did not ask about the resident’s specific preferences for transfer locations and did not consistently document conversations about discharge planning. The Administrator stated they were planning to discharge the resident, believed the resident did not need LTC based on level of care, and noted that the care plan still reflected an initial plan for LTC and had not been updated. The Administrator also acknowledged that sending the resident back to a motel would not be a safe discharge and that the resident had not been issued a formal discharge notice, while also indicating that a 30-day discharge could be pursued if the resident declined offered placements.
Failure to Provide Medically-Related Social Services and Community Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services and appropriate discharge planning for one cognitively intact resident with significant physical impairments. The facility’s Discharges policy required Social Services to assess discharge potential upon admission, involve the IDT in person-centered discharge planning, arrange outside services and equipment, and complete a discharge form outlining care needs at home. The resident’s face sheet and initial MDS showed diagnoses of hemiplegia, aphasia, and unsteadiness on feet, with the resident assessed as cognitively intact. The resident’s care plan documented a wish to remain for LTC, with planned evaluation of motivation to return to the community and identification of limitations, risks, benefits, and needs for maximum independence, as well as recognition of impaired cognitive function, ADL deficits, and fall risk. Progress notes by the Director of Care Transitions from an Initial Care Management meeting documented that the resident’s plan for living arrangements had not changed, there were no environmental barriers impacting discharge, there were no remaining medical education needs, and that stairs and bathing were functional and ADL barriers at discharge. However, there was no documentation of referrals to needed outside services or assistance with identifying community placement options, despite the resident’s physical limitations and the facility’s policy requirements. The resident later reported recognizing a need for a safe place with shelter, food, showers, and care, and stated that the Administrator and DCT had told them they could not stay and needed to find somewhere else to go. The resident indicated the DCT was working on a transfer to another facility, but the resident was unsure about the type of placement being pursued and reported not receiving any information about assistance from outside agencies. In interviews, the DCT stated the resident had received a NOMNC, was past the last Medicare-covered day, and also had Medicaid. The DCT reported sending a referral to another facility that declined due to the resident’s behavior, acknowledged that no discharge letter had been given, and confirmed that no other referrals to available community resources were provided, despite acknowledging the resident’s right to return to the community. The DCT said the current goal was to move forward with a transfer and that a discharge notice had not been issued, and also admitted not asking the resident about preferences for transfers and not always documenting conversations. The Administrator stated they were actively seeking placement at other facilities, that the resident had to accept referrals, and that there were no referrals to outside agencies because some required three months in LTC, which was not planned. The Administrator also stated that if the resident did not accept placement, a 30-day discharge would be issued based on offering safe placement and the resident declining. These actions and omissions demonstrate that the facility did not plan for or refer the resident to potential community services necessary for a successful and appropriate discharge back to the community, contrary to its own discharge policy and the resident’s rights.
Environmental Safety and Maintenance Deficiencies in Resident Rooms and Restrooms
Penalty
Summary
Surveyors identified environmental deficiencies involving climate control units, restroom ceiling vents, a restroom handrail, and a wall guard in multiple resident rooms. During observations conducted with the Facility Maintenance Director, surveyors found an ointment bottle, a fork, and a small medication cup inside the climate control unit in one resident room, with the unit’s grate cover missing. Additional resident rooms were noted to have climate control units with heavy dust and cobweb buildup or large amounts of dust and debris. The Facility Maintenance Director stated that climate control units should be checked monthly for debris buildup. Further observations showed restroom ceiling vent covers in several resident rooms that were loose and not firmly attached to the ceiling, and one restroom where the ceiling vent cover was completely absent. A restroom handrail in another resident room was repeatedly observed on different days to be not firmly attached to the wall. In a separate room, the wall guard was seen peeling away from the wall with screws protruding as it detached. The Facility Maintenance Director reported having checked some vents in the past, stated being unaware of the loose wall guard, and indicated a belief that facility staff were generally good about entering such issues into the TELS work order system. These conditions potentially affected at least 15 residents who resided in or used the affected areas, in a facility with a census of 105 residents.
Dust Buildup on Vents and Resident Room Fans
Penalty
Summary
The facility failed to maintain the ceiling vents in the A Hall shower room free from a heavy buildup of dust and failed to keep tabletop fans in multiple resident areas free from a heavy buildup of dust, including resident rooms B10, B5, B4, C5, Resident #33's room, and Resident #101's room. During observation with the Facility Maintenance Director, two ceiling vents in the A Hall shower room were noted to have heavy dust buildup, and the Director stated a cleaning schedule for those vents had not yet been developed after taking over as Director in December 2025. Additional observations showed heavy dust buildup on tabletop fans in several resident rooms. Resident #33, who was cognitively intact per the quarterly MDS dated 4/18/25, stated staff cleaned the fan every now and then but would prefer it be cleaned more often. Resident #101, also cognitively intact per the quarterly MDS, stated it had been a while since the fan on his/her side of the room had been cleaned and that he/she would appreciate it if staff cleaned it a little bit more. In other rooms, the Facility Maintenance Director observed heavy dust buildup on fans in rooms B5, B4, C5, and B10, with no residents present in some rooms to interview at the time of observation.
Food Preferences and Alternative Meal Choices Not Honored
Penalty
Summary
The facility failed to ensure that resident food preferences were honored and that alternative menu choices were provided for three sampled residents who ate in their rooms. The cited policy stated that if a resident did not like the food served, a substitute was to be offered, and that individual preferences regarding where residents ate were to be accommodated as much as possible. The census was 105 residents, and the deficiency was identified during observation, interview, and record review. Resident #95 had diagnoses including difficulty walking, dysphagia, and muscle weakness, and his/her care plan identified a potential for altered nutrition and hydration related to risk for malnutrition and acute illness. The record contained no documentation that the resident refused meals or had meal preferences documented. During interviews, the resident stated that staff did not let him/her choose meal items, that food was cold, and that no alternative was offered. Observations showed the resident eating in bed with meal trays in the room, including one breakfast tray that did not include oatmeal listed on the meal ticket and another tray where oatmeal was listed but not provided. The dislikes and other sections on the meal ticket were blank, and the resident refused one meal because it was cold and did not contain the items wanted. Resident #110 and Resident #112, both of whom ate in their rooms, stated during interview that no one asked what they wanted to eat and that they received whatever was brought to them. Observation of their meal tickets showed no alternative choices offered, and no menu was available in the room. In the dining room, observations on multiple days showed no alternative menus on the menu board or available to residents. Staff and leadership interviews stated that alternatives were available, that preferences should be communicated through meal tickets, progress notes, or dietary orders, and that residents could request other items; however, the observed meal service for these residents did not reflect those stated practices.
Kitchen and Dining Area Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to keep the kitchen and dining areas clean and maintained in accordance with professional standards. During observations, dust was noted on vents and ceiling lights throughout the kitchen and over-serving area, a large bag of breadcrumbs was left open, and the flour bin door was open. In the dining room, dried spilled residue was observed throughout the sitting area on multiple occasions, along with a fresh liquid spill near a support column and later dried residue in the same area. The dining room floors were not mopped as observed over several days. The facility also had maintenance and sanitation issues in the kitchen and dish machine room. Observations showed holes in the wall adjacent to the serving area, metal trim coming off a corner near the bread rack, and no drain cover over the drain in the dish machine room. The area around the piping under the prewash sink was not sealed, with a large hole and wall debris spilling onto the floor, and a black substance potentially mold was seen on the piping and around the hole. Dust was also observed on the black fan in the dish machine room. The Executive Chef stated the holes in the walls and the drain cover should have been reported to maintenance in the tracking system, and that the dining room should be swept and mopped after every meal.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for residents on Enhanced Barrier Precautions (EBP), and survey observations showed repeated lapses in PPE use and hand hygiene during resident care. For one resident with a gastrostomy tube, cognitive impairment, and total dependence for care, staff entered the room without gowns, gloves were applied without hand hygiene, and handwashing was not performed after glove removal or between dirty and clean tasks during incontinence care. The resident’s care involved repeated repositioning, cleaning, and linen changes, yet staff were observed moving from soiled to clean tasks without sanitizing or washing hands and without consistently wearing the required gown. A second resident with diabetes, anemia, atrial fibrillation, kidney failure, seizures, and a urinary catheter was also on EBP for wounds, a urinary catheter, and a nephrostomy tube. During observation, a CNA entered the room without a gown, did not sanitize hands before gloving, repositioned the resident, and then exited without hand hygiene after glove removal. The resident’s catheter collection bag was observed at the side of the bed below the bladder, and the nephrostomy bag was lying on the bed. Staff interviews confirmed they were expected to wear gowns for residents on EBP and to perform hand hygiene when entering and leaving rooms, but the observed practice did not match those expectations. For a third resident with bladder cancer and urinary retention, the suprapubic catheter drainage bag and tubing were observed dragging on the floor underneath a wheelchair, with thick yellow substance in the tubing at one point and the bag again observed dragging on the ground on another occasion. During catheter care, the resident did not have EBP signage posted, and a CNA entered the room with only gloves, emptied the drainage bag, and provided incontinent care without a gown or mask. Interviews with staff and leadership confirmed the resident was expected to be on EBP, that the drainage bag should not touch the ground, and that direct care for the resident should include gown, gloves, and mask, yet these practices were not followed during the observed care.
Absent Negative Airflow in Multiple Resident Room Restrooms
Penalty
Summary
The facility failed to ensure negative airflow in the restrooms of multiple resident rooms, including H7, H6, H5, H4, H2, H1, G8, G5, G7, G9, G12, G14, D8, D7, D4, D5, D3, D2, and D1. Based on observation with the Facility Maintenance Director and the Senior [NAME] President of Facility Services, surveyors tested airflow by holding tissue paper to the ceiling vent; in each of the listed restrooms, the paper fell rather than being drawn to the vent, indicating the absence of negative airflow. The observations were made in the resident rooms identified in the report, and the deficiency potentially affected 23 residents who lived in those rooms. During interview, the Facility Maintenance Director stated that he/she had not checked for negative airflow since starting in the role and had not been told to check for negative airflow in resident rooms. The report documents repeated observations of absent negative airflow across multiple resident room restrooms on two survey dates, along with the maintenance director’s statement regarding the lack of checks for negative airflow.
Failure to Address Shower Refusals and Maintain Call Light Accessibility
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s repeated refusals of scheduled showers were assessed, documented, and addressed in relation to the resident’s bathing preferences, and the failure to ensure another resident’s call light was kept within reach despite care plan requirements and facility policy. One resident was admitted with adult failure to thrive and a need for assistance with personal care, was cognitively intact, and able to understand and make needs known. The facility assigned shower days and times by room number, placing this resident on an evening/night schedule twice weekly, with instructions that CNAs report refusals to the charge nurse and obtain resident or guest signatures on shower sheets. The resident’s care plan identified ADL self-care deficits, need for assistance with showering, delirium, delusions, and known noncompliance with medical treatment. From early December through early January, the resident refused all offered evening/night showers on multiple assigned days. Documented reasons included that it was too late for a shower and a preference for morning showers. Some refusal entries lacked the resident’s signature, and there was no documentation on the shower sheets that refusals were addressed by licensed nursing staff or that the resident was educated about noncompliance with bathing. Review of the medical record for the same period showed no nursing documentation related to the repeated evening shower refusals and no new interventions regarding bathing preferences or changes to shower days/times. Although the care plan was updated to note a history of refusal of care, treatments, and medications, there were no added interventions specifically addressing shower timing or offering alternative shower schedules aligned with the resident’s stated preference for morning showers. The second deficiency concerns a resident with dementia, muscle weakness, difficulty walking, a need for assistance with personal care, and a history of falls, who required moderate to maximal assistance with self-care and mobility. Observations over several days showed this resident in bed or in a wheelchair with the call light consistently located behind the nightstand and not within reach. The resident reported that staff kept him/her in bed most of the time due to frequent falls and that night shift staff purposefully placed the call light out of reach, leaving the resident unable to get up independently to use the bathroom and having to wait until staff entered the room. The resident’s care plan required staff to ensure a safe environment by keeping the call light within reach, to encourage and educate the resident on using the call light for assistance, and to ensure it was within reach at all times. Despite staff interviews confirming knowledge of policies that call lights must be within reach and checked before leaving the room, repeated observations documented that this resident’s call light remained behind the nightstand and inaccessible.
Insulin Pen Septum Not Cleansed Before Administration
Penalty
Summary
The facility failed to meet professional standards of practice when administering insulin to two residents with diabetes by not cleansing the insulin pen rubber septum with alcohol before attaching the pen needle and giving the injection. Resident #75 was admitted with a diagnosis of Diabetes Mellitus and had an order for Humalog 20 units every day before meals. During observation, an LPN applied the needle, drew up insulin, discarded it because the wrong amount was drawn, removed the needle, did not wipe the pen septum with alcohol, replaced the needle, primed the pen, and then drew up 20 units of insulin. Resident #115 was admitted with a diagnosis of Diabetes Mellitus and had orders for Novolog FlexPen on a sliding scale before meals and at bedtime, as well as Lantus SoloStar 10 units subcutaneously two times a day. During observation, an LPN did not clean either the Novolog or Lantus insulin pen septum with alcohol before applying the pen needle, priming, and drawing up the medication. In interview, the LPN stated the facility policy was to wipe the insulin pen with alcohol before attaching the needle, and the CNO stated nurses were expected to clean the insulin pens with alcohol prior to attaching the pen needle.
Call Light and Ordered Boots Not Provided as Directed
Penalty
Summary
The facility failed to ensure that Resident #93 had access to an adaptive call light device and that the call light remained within reach. The resident was admitted with diagnoses including protein-calorie malnutrition, palliative care, cognitive communication deficit, difficulty walking, legal blindness, senile degeneration of the brain, and type 2 diabetes mellitus. The quarterly MDS showed the resident had severely impaired vision, was severely cognitively impaired, was completely dependent for all ADLs and transfers, and was at risk for pressure ulcer/injury development. The resident’s care plan directed staff to keep the call light and other key items within reach, tell the resident where items were placed, encourage use of a bell to call for assistance, ensure the call light was within reach, and provide a soft touch call light for use. The resident also had a physician order for Prevalon boots to be worn when in bed, and the care plan included pressure injury prevention interventions with bunny boots to both feet for pressure relief. During multiple observations, the resident was in bed without Prevalon boots applied. The standard call light was observed on the floor between the bed and nightstand, tied to the lower bed frame, and not within the resident’s reach. On each observation, there was no adaptive call light present. Staff interviews reflected uncertainty about the resident’s specific call light device and pressure injury prevention equipment, while the CNO stated staff were expected to keep call lights within reach, follow the care plan, and have Prevalon boots on the resident while in bed as ordered.
Lack of Physician Orders for CPAP Use
Penalty
Summary
The facility failed to ensure there were physician orders for the use of a CPAP machine for one resident with diagnoses including acute respiratory failure, shortness of breath, obstructive sleep apnea, heart failure, hypoxemia, and need for assistance with personal care. The resident’s annual MDS showed the resident was cognitively intact, dependent on staff for self-care, independent for functional cognition, and dependent on a motorized wheelchair, but CPAP was not marked as being used and respiratory failure was not marked yes. The resident’s current physician orders for January 2026 contained no order for CPAP use prior to 1/15/26, and the care plan also did not mention CPAP use or related interventions prior to that date. Despite the lack of orders and care plan documentation, staff documented in the oxygen saturation daily records that the resident used a CPAP starting on 1/2/26. Observations on 1/12/26, 1/13/26, 1/15/26, and 1/16/26 showed the CPAP machine on the nightstand next to the resident’s bed, and on 1/16/26 the mask was lying on the bed. During interviews, a CNA stated the resident wore a CPAP every night, staff helped put it on at night, and there should be orders for it. Another CNA and an LPN were unable to confirm details about the CPAP, but both stated that if a resident needed a CPAP, nursing staff would be responsible for it and that an order should exist. The MDS/Care Plan Coordinator stated the resident did not have the CPAP when admitted and first heard about the resident having one on 1/15/26, and both the ACNO and CNO stated there should have been orders when a resident wore a CPAP. The resident stated the CPAP had been used since 2016, had to be worn every night, and staff needed to put it on each night. The ACNO and CNO also stated the CPAP should have been documented in the care plan and MDS, and the CNO said the charge nurse recorded oxygen saturation data while the resident wore the CPAP.
Incomplete dialysis access monitoring and care planning
Penalty
Summary
The facility failed to ensure dialysis orders for monitoring the dialysis site were complete for a resident who received dialysis services. The resident had diagnoses including end stage renal disease, dependence on dialysis, diabetes, high blood pressure, and high cholesterol. The resident’s care plan showed in-house dialysis on Monday, Wednesday, and Friday and included interventions to check and change the dressing at the access site, monitor for bleeding after dialysis, and monitor for signs and symptoms of infection, but it did not identify the dialysis access site or the type of access site, and it did not describe how the facility was to monitor the access site. The resident’s physician orders showed in-house dialysis on Monday, Wednesday, and Friday, removal of the dressing from the dialysis access site the next day after treatment, and a CVC location of the right chest. The orders did not show how the facility was to monitor the CVC, and there were no orders showing the resident had a permanent access site such as a fistula, where it was located, or how to care for or monitor that site. Facility staff and dialysis staff gave differing descriptions of what monitoring was expected, including visual checks for infection, removal of dressings after dialysis, and documentation on the MAR, but the orders and care plan did not reflect daily thrill and bruit checks. During observation, the resident was in a wheelchair and had a right below-knee amputation with a prosthetic. The resident’s left forearm showed red bruising and several puncture wounds at the fistula site, and tubing from the right chest CVC was covered with a white cotton 4x4 pad. The resident stated that dialysis was normally performed through the fistula, that the CVC was used when the fistula was difficult to access, that the facility nurses usually removed the fistula bandage and checked for redness or bruising after dialysis, and that not all nurses checked the fistula every day or used a stethoscope to listen to it. Staff interviews confirmed that the facility did not consistently monitor the dialysis access sites according to a clear protocol, did not document the monitoring consistently, and did not have a care plan that described how the dialysis access site would be monitored.
Delayed Dental Follow-Up and Treatment
Penalty
Summary
The facility failed to ensure follow-up dental appointments were made for one resident with poor dentition and cracked teeth, resulting in delayed dental treatment. The resident was admitted with anemia and cirrhosis of the liver, had a physician order for a dental referral due to poor dentition and cracked teeth, and had a dental consult order already in place. The resident’s care plan identified oral/dental health problems and directed staff to coordinate dental care and monitor for oral symptoms, but the record did not show documentation of follow-up dental appointments or reasons for delay over several months. The resident’s record showed a dental visit in August 2025 with referral for surgery with sedation for edentulation and a pending denture appointment after tooth removal. However, from October 2025 through January 2026, there was no documentation of additional dental follow-up appointments, dental recommendations, or nursing assessments related to ongoing dental pain or discomfort. The resident later developed a dental abscess and was started on clindamycin, with a new order to schedule follow-up with a local hospital oral surgeon. At the time of survey, the resident reported mouth pain involving the gums, tongue, and jaw, difficulty chewing and drinking, and sharp jagged teeth cutting the cheeks. Staff interviews showed the LPN had not assessed the resident for mouth pain and was not aware of the resident’s current complaints, while the Social Services Designee stated the facility lacked documentation from prior dental visits and follow-up recommendations. The Chief Nursing Officer stated the resident should not have had to wait 4-5 months for follow-up dental treatment for ongoing dental issues.
Facility Fails to Maintain Comfortable Environment Due to High Temperatures
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by room temperatures ranging from 81.8°F to 87.0°F, which exceeded the facility's policy of maintaining temperatures between 71°F and 81°F. The facility's Emergency Operations Plan required action when the heat index inside exceeded 80°F, but the facility did not have a comprehensive monitoring system in place to document air temperatures or conduct random monitoring. This deficiency had the potential to affect all residents in the building, with a census of 116 residents. Observations and interviews revealed that the facility's cooling system, which included a boiler system and air handler/chiller unit, was not effectively maintaining the desired temperature. The Director of Maintenance (DOM) acknowledged that regular temperature logs were not kept unless there was a problem, and the system was running about 20 degrees cooler than outside temperatures. Several wall units were not functioning, and parts were delayed, contributing to the elevated temperatures in resident rooms and common areas. Residents and staff reported discomfort due to the heat, with some residents experiencing difficulty breathing and others using fans to cope with the high temperatures. Staff interviews indicated that the issue had persisted for several days, with some staff members failing to report the problem or take action. The facility's response was delayed, and the air conditioning company was only contacted after the state surveyor's visit, revealing a lack of proactive measures to address the temperature issues.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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