James River Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 3550 East Battlefield, Springfield, Missouri 65809
- CMS Provider Number
- 265664
- Inspections on file
- 19
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at James River Nursing And Rehabilitation during CMS and state inspections, most recent first.
Three residents who required assistance with bathing did not consistently receive showers according to their care plans and preferences, often going extended periods without bathing. Residents reported feeling dirty and uncomfortable, and staff interviews confirmed that staffing shortages and turnover led to missed showers, with management aware of the ongoing concerns.
The facility failed to ensure cups and glasses were air-dried before storage, leading to potential contamination risks. Observations showed improper storage of 102 cups/glasses, contrary to FDA guidelines. Interviews revealed staff were unaware of proper drying procedures, and the facility lacked a relevant policy.
A facility failed to maintain resident dignity and respect in two incidents. In one, a resident felt intimidated during a group discussion with staff about care prioritization. In another, a CNA handled a cognitively impaired resident roughly and used derogatory language. These actions violated the facility's policies on resident dignity.
The facility failed to provide a clean, safe, and homelike environment for residents, as evidenced by unaddressed maintenance issues. A resident reported trash and stained ceilings, another faced wall damage from a power chair, and a third had a loose electrical outlet affecting device charging. Despite residents notifying staff, these issues persisted, indicating a breakdown in maintenance reporting and follow-up.
The facility failed to secure medication carts, leaving them unlocked and unattended on three occasions. An LPN, a CMT, and the DON were involved in incidents where carts were left unsecured in hallways and near resident areas. Staff interviews confirmed that carts should be locked when unattended, but no formal policy was provided.
Facility staff failed to maintain proper infection control during medication administration and glucometer disinfection. An LPN used a gloved finger to stir medications for a resident with complex medical needs, while a CNA/CMT improperly handled spilled medications for another resident. Additionally, staff did not follow proper disinfection procedures for glucometers used on multiple residents, risking cross-contamination. These actions were acknowledged as breaches of infection control protocols by facility leadership.
The facility failed to provide scheduled showers to two residents, impacting their right to self-determination. One resident, with multiple health conditions, received showers sporadically, leading to feelings of uncleanliness. Another resident, also with significant health issues, experienced long delays between showers, despite needing substantial assistance. Staff interviews revealed inconsistencies in shower provision, with the DON and Administrator acknowledging the issue.
A resident's privacy was compromised when a CNA left the room door open during incontinence care, exposing the resident to the hallway. Despite the resident's discomfort and the facility's policy on maintaining privacy, the door was left open due to the roommate's preference. Staff interviews confirmed that privacy should have been ensured by closing the door or using the privacy curtain.
A resident was admitted to the facility without the required PASARR screening, which is necessary to identify mental disorders or intellectual disabilities. Despite the facility's policy requiring a Level I PASARR before admission, the documentation was missing from both electronic and paper records. The MDS Coordinator and other staff acknowledged the oversight, noting the resident's long-term stay and relevant diagnoses.
A resident in an LTC facility did not receive necessary services for personal hygiene, as staff failed to provide adequate peri-care and change urine-soaked items. The resident, dependent on staff for mobility and hygiene, was observed sitting in a urine-soaked wheelchair pad. Staff did not follow proper procedures for incontinent care, including hand hygiene and changing soiled clothing, leading to a deficiency.
A resident's code status was inconsistently documented across their medical records, with a DNR order on the face sheet and a full code status in the care plan. Staff interviews revealed confusion about who was responsible for ensuring consistency, despite the information being available in multiple locations. The DON and Administrator acknowledged the need for consistent documentation, but discrepancies remained.
A facility failed to document a diagnosis justifying catheter use for a resident, despite policy requiring such documentation. The resident's records, including the MDS and physician's orders, lacked a diagnosis for the catheter, and staff interviews confirmed the expectation for such documentation. The resident had a history of kidney complications and UTIs, but these were not linked to the catheter use in the records.
A facility failed to obtain a physician's order for a resident's CPAP therapy, resulting in inconsistent application of the CPAP machine at bedtime. The resident, who had chronic respiratory failure and was cognitively intact, reported that staff did not always assist with the CPAP. Interviews with staff revealed a lack of awareness and communication regarding the resident's CPAP needs, and there was no documented order for the therapy in the resident's records.
A resident with significant health conditions, including bilateral above-knee amputations, experienced loose bed rails that were not properly maintained or documented by the facility staff. Despite the resident's notification to staff, the issue persisted, highlighting a deficiency in the facility's monitoring and maintenance processes.
A facility experienced a 14% medication error rate due to improper administration practices. An LPN failed to prime an insulin pen before use, and another LPN mixed medications without a physician's order for a resident with a PEG tube. Staff interviews confirmed these actions were against facility protocols.
A resident with type two diabetes received insulin without the pen being primed, as required by the manufacturer's instructions. An LPN administered 4 units of insulin without priming the NovoLog FlexPen, despite the facility's expectation to prime before each use. The resident was cognitively intact and received insulin injections daily.
The facility failed to provide timely written notifications to residents and their representatives regarding hospital transfers. Three residents did not receive written notices in a timely manner, with delays ranging from 30 to 47 days. Staff interviews revealed a lack of awareness and implementation of the process for sending out these notices, and the Business Office Manager admitted to delays due to availability. The Administrator confirmed that the facility did not issue written transfer notices, relying instead on verbal communication and monthly logs sent to the Ombudsman.
The facility failed to protect residents from misappropriation when an LPN was found with multiple pills in their pockets, leading to 17 missing doses of medication affecting twelve residents. The facility's policies on abuse, neglect, exploitation, and misappropriation were not followed, and the investigation process was not thoroughly documented.
The facility failed to ensure complete and accurate medical records for four residents, as staff did not document or verify the administration of prescribed treatments. The ADON assumed treatments were completed by a nurse who left unexpectedly and did not confirm with the residents.
The facility failed to administer a resident's as-needed pain medication despite multiple requests and visible signs of pain. The resident, with severe sepsis and other conditions, reported significant pain, but the medication was not given, and proper documentation was lacking.
Failure to Honor Resident Shower Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring reasonable shower preferences for three residents. Observations, interviews, and record reviews revealed that these residents, all of whom had no cognitive impairment and required partial to moderate assistance with bathing, did not consistently receive showers according to their stated preferences or care plans. Documentation showed significant gaps between showers, with some residents going up to 13 days without a shower, despite care plans indicating a preference for two showers per week on specific days. There was no documentation of resident refusals or additional showers provided. Interviews with the affected residents confirmed that they felt dirty, had oily hair, and experienced discomfort such as itching and skin issues due to infrequent bathing. One resident with cellulitis reported that infrequent showers led to skin cracking under abdominal folds. All three residents expressed a desire for more frequent showers and indicated that their preferences were not being met, often receiving only one shower per week instead of the two specified in their care plans. Staff interviews corroborated these findings, with CNAs and LPNs acknowledging that residents were not receiving the required number of showers due to staffing shortages and turnover among shower aides. Staff reported being pulled to other duties, which resulted in missed showers, and confirmed that residents had voiced concerns about the lack of regular bathing. Management was aware of these concerns, and staff were unsure how many showers residents actually received each week, despite a process for reviewing shower sheets.
Improper Drying and Storage of Cups and Glasses
Penalty
Summary
The facility failed to adhere to professional standards for food safety by not ensuring that cups and glasses were air-dried before storage, potentially leading to contamination or bacterial growth. Observations on two separate occasions revealed that a total of 102 small water and juice cups/glasses were stored upside down in a manner that trapped water, preventing proper air drying. This practice was contrary to the 1999 Food Code issued by the FDA, which mandates that equipment and utensils must be air-dried before being stored to prevent microorganism growth. Interviews with dietary staff and the dietary manager indicated a lack of awareness and understanding of the proper procedures for drying dishes. Dietary aides admitted to not knowing that dishes needed to be completely dry before storage, while the dietary manager was unaware of the improper storage method being used. The facility also lacked a specific policy regarding the air drying of dishes, and the administrator acknowledged the absence of such a policy and the inadequate air gap for drying, which contributed to the deficiency.
Inappropriate Staff Behavior and Lack of Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by two separate incidents involving inappropriate staff behavior. In the first incident, a resident with multiple sclerosis and other health conditions was involved in a disagreement with CNAs regarding the prioritization of care. The situation escalated when the resident was taken to the library for a discussion with multiple staff members, including an LPN and an ADON. The resident felt intimidated by the presence of multiple staff members and the loud, demanding tone used by the LPN, which was audible and visible to others in the facility. In the second incident, a resident with severe cognitive impairment and multiple health issues was subjected to rough handling and verbal abuse by a CNA. The CNA was reported to have transferred the resident roughly and used derogatory language, referring to the resident as a "fucking goat" in the presence of other staff and the resident. This behavior was corroborated by multiple staff members who witnessed the incident, and it was noted that the CNA had a history of being rude and using inappropriate language with residents. These incidents highlight a failure to adhere to the facility's policies on treating residents with dignity and respect. The staff's actions, including the use of inappropriate language and rough handling, were not in line with the facility's guidelines for maintaining a respectful and dignified environment for residents. The facility's policies emphasize the importance of treating residents with kindness and respect, which was not upheld in these cases.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident #70 reported trash and debris under the bed and recliner, as well as stained ceilings, which were confirmed upon observation. The maintenance request log showed a previous report of a leak by the smoke detector, but no entry regarding the ceiling damage above the bed was documented. This indicates a lack of follow-up on maintenance issues, contributing to the resident's discomfort and perception of an unclean environment. Resident #30 experienced wall damage in their room, reportedly caused by staff driving a power chair into the wall, which left the metal drywall corner bracket exposed. The resident also noted peeling wallpaper above their bed, which they attempted to cover with a plant. Despite the resident's awareness of the maintenance staff's efforts to address repairs, there were no documented maintenance requests for the wall damage, highlighting a gap in communication and documentation of maintenance needs. Resident #49 faced issues with a loose electrical outlet that could not securely hold plugs, affecting their ability to charge devices like a cell phone. The resident had informed staff multiple times, but the issue persisted, as observed with the CPAP machine's plug hanging loosely from the outlet. Interviews with staff, including the Maintenance Director, revealed a lack of awareness of the specific issues in the residents' rooms, suggesting a breakdown in the reporting and addressing of maintenance concerns. The facility also lacked a policy for monitoring electrical outlets, further contributing to the oversight of this deficiency.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During observations, three separate incidents were noted where medication carts were left unlocked and unattended. On one occasion, an LPN left a medication cart unlocked in the hallway while administering medications to a resident in their room. The Assistant Director of Nursing later locked the cart. In another instance, a medication cart was left unlocked near a resident lounge area, unattended by staff, until the Director of Nursing secured it. A third observation noted a medication cart left unlocked in a hallway, with several residents and staff passing by, until a Certified Medication Technician locked it. Interviews with various staff members, including a CNA/CMT, an Admissions Nurse, and the Director of Nursing, confirmed that the facility's practice is to lock medication carts when not attended by staff. However, the facility did not provide a policy regarding the storage of medications, indicating a lack of formal guidance on this critical safety procedure. The facility census at the time was 101, highlighting the potential risk posed by the unsecured medication carts in a busy environment.
Infection Control Deficiencies in Medication Administration and Glucometer Disinfection
Penalty
Summary
The facility staff failed to maintain proper infection control practices during medication administration and glucometer disinfection, leading to deficiencies in care. For Resident #254, a Licensed Practical Nurse (LPN) was observed using a gloved finger to stir crushed medications in a cup before administering them via a peg-tube. This action was acknowledged by multiple staff members, including the Director of Nursing (DON) and Administrator, as unacceptable and a breach of infection control protocols. Resident #254 had a complex medical history, including chronic obstructive pulmonary disease, respiratory failure, and dysphagia, requiring careful medication management. In another incident, a Certified Nursing Assistant/Medication Technician (CNA/CMT) was observed handling medications for Resident #8 inappropriately. After spilling pills from a medication cup onto a tapestry runner, the CMT used a plastic spoon to scoop them back into the cup and administered them to the resident. This action was contrary to infection control guidelines, which require discarding dropped medications. Resident #8 had severe cognitive impairment and multiple health conditions, including congestive heart failure and chronic renal failure, necessitating precise medication administration. The facility also failed to properly disinfect glucometers used for blood glucose testing for Residents #74, #22, and #14. Observations revealed that staff did not follow the manufacturer's disinfection procedures, such as thoroughly wiping the glucometer with a disinfectant wipe and allowing it to air dry. Instead, staff wrapped the glucometer in a sani-wipe without proper cleaning, potentially leading to cross-contamination. These lapses in infection control were acknowledged by the Admissions Coordinator and DON, who emphasized the importance of adhering to infection control guidelines.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to uphold the residents' right to self-determination by not providing showers or baths as requested and care planned for two residents. Resident #46, who has a history of cerebral infarction, COPD, SLE, cognitive communication deficit, and CHF, was scheduled to receive showers twice a week. However, records show that the resident only received showers sporadically, with gaps ranging from seven to fourteen days between showers. The resident expressed dissatisfaction with the infrequency of showers, stating that once a week was insufficient and left them feeling dirty and tired. Resident #49, with diagnoses including metabolic encephalopathy, type 2 diabetes, bilateral leg amputation, CKD, CHF, and chronic respiratory failure, also experienced a lack of regular bathing. Despite being cognitively intact and requiring substantial assistance, the resident received showers or bed baths with significant delays, sometimes up to a month apart. The resident expressed feeling unclean and uncomfortable due to the infrequent bathing schedule and mentioned a previous agreement for more frequent showers, which was not being honored. Interviews with facility staff, including CNAs and the DON, revealed inconsistencies in the provision of showers, with some staff unaware of the residents' needs or the facility's policies. The DON and Administrator acknowledged that residents should be offered showers twice a week, regardless of hospice status, and that the current practice of extended delays between showers was not acceptable.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during the provision of personal care. An observation revealed that the door to the resident's room was left open while a Certified Nursing Assistant (CNA) was performing incontinence care, exposing the resident's unclothed back to anyone passing by in the hallway. The resident, who has moderate cognitive impairment and is dependent on staff for personal care, expressed discomfort with being exposed, although noted that their roommate preferred the door open due to claustrophobia. Interviews with various staff members, including a CNA/Certified Medication Technician, a Licensed Practical Nurse (LPN), the Admissions Coordinator, and the Director of Nursing (DON), confirmed that it is against facility policy to leave a resident exposed in such a manner. The staff acknowledged that privacy should be maintained by closing the door or at least pulling the privacy curtain during personal care. The facility's policy on dignity emphasizes the importance of respecting residents' privacy and ensuring their well-being, which was not adhered to in this instance.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident prior to or upon admission. The facility's policy mandates that all new admissions and readmissions undergo a Level I PASARR screening to identify any mental disorders, intellectual disabilities, or related disorders. If the Level I screening indicates potential issues, a Level II evaluation is required. However, for one resident, no Level I or Level II PASARR was found in the records, despite the resident having diagnoses that include intellectual disabilities and dementia. The MDS Coordinator, responsible for PASARRs, stated that Level I screenings are typically completed at the hospital before admission, or by the facility if the resident comes from home. The Coordinator believed the resident should have had a PASARR completed due to their long-term stay at the facility. However, upon review, neither the electronic medical record nor the paper records contained the necessary PASARR documentation. The Director of Nursing and Administrator confirmed that a Level I PASARR should have been completed prior to admission, but it was not found in the records.
Inadequate Incontinent Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, the staff did not provide adequate peri-care and failed to change urine-soaked items for a resident who was incontinent of bladder. The resident, who was cognitively intact but dependent on staff for mobility and personal hygiene, was observed sitting in a urine-soaked wheelchair pad while waiting for care. During the observed incident, multiple staff members, including CNAs and the ADON, were involved in transferring the resident using a Hoyer lift. Despite the presence of urine on the resident's wheelchair pad and floor, the staff did not change the wet Hoyer sling or the resident's urine-soaked pants. The CNAs also failed to perform proper peri-care, using the same wipe for multiple areas and not changing gloves between dirty and clean tasks. Interviews with various staff members, including a CNA/CMT, LPN, Admissions Coordinator, and the DON, revealed that the facility's expected procedures for incontinent care were not followed. These procedures included performing hand hygiene, using one wipe per swipe, and ensuring all clothing and linens were clean before being put back on the resident. The staff's actions during the incident did not align with these expectations, leading to the deficiency.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was consistent throughout their medical record. The resident, who had a history of cerebral infarction, altered mental status, COPD, chronic respiratory failure with hypoxia, and systemic lupus erythematosus, was documented as having a do not resuscitate (DNR) order on their face sheet. However, the care plan indicated the resident was full code, meaning they wished to receive CPR if their heart or breathing stopped. Interviews with various staff members, including CNAs, CMTs, LPNs, RNs, and the Social Service Director, revealed that the code status information was available in multiple locations, such as the electronic medical record (EMR), the resident's closet care plan, and the face sheet. Despite this, there was a lack of consistency in ensuring that the code status matched across all these records. Staff members believed that the information should match and that audits were conducted to ensure accuracy, but there was confusion about who was responsible for these audits. The Director of Nursing and the Administrator both acknowledged that the code status should be consistent throughout the resident's chart. They explained that the admission nurse was responsible for entering the code status information, and a match back audit was supposed to be conducted 24 hours after orders were entered. However, discrepancies were noted, and it was unclear who was responsible for ensuring the accuracy of the code status across all records, leading to the deficiency identified by the surveyors.
Lack of Documentation for Catheter Use in Resident
Penalty
Summary
The facility failed to ensure proper documentation and justification for the use of a catheter in a resident's medical record. Specifically, Resident #47's medical record did not contain a diagnosis to justify the use of a catheter, despite the resident arriving at the facility with a catheter already in place. The facility's policy on catheter care, revised in August 2022, requires staff to review and document the clinical indications for catheter use prior to insertion, which was not adhered to in this case. The resident's face sheet, progress notes, Minimum Data Set (MDS), physician's orders, care plan, and Treatment Administration Record (TAR) all lacked documentation of a diagnosis that warranted the catheter use. Interviews with facility staff, including the Infection Control Nurse, Admissions Coordinator, Director of Nursing (DON), and Administrator, revealed that there was an expectation for a diagnosis to be documented for catheter use. The staff acknowledged that physician orders should be based on diagnoses, and the absence of such documentation was a lapse in following standard practice. The facility census at the time was 101, and the resident had a history of kidney complications and urinary tract infections (UTIs), but these were not explicitly linked to the need for a catheter in the documentation.
Failure to Obtain Physician's Order for CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea by not obtaining a physician's order for the use of a CPAP machine at bedtime. The resident, who was cognitively intact and had a history of chronic respiratory failure with hypoxia, had a CPAP machine at their bedside but reported that staff did not always apply the mask or turn on the machine at night. The resident expressed a willingness to use the CPAP if assisted by staff, but there was no documented order for CPAP therapy in the resident's Treatment Administration Record (TAR) or Medication Administration Record (MAR). Interviews with facility staff, including LPNs and the Director of Nursing, revealed a lack of awareness and communication regarding the resident's CPAP therapy needs. The staff believed that CPAP treatment would be documented in the nursing TAR, but there was no confirmation of its presence. The Director of Nursing and the Administrator acknowledged that there should have been an order for CPAP use, including pressure settings, and that nurses were responsible for ensuring the CPAP was applied. The deficiency was identified through observation, interviews, and record reviews, highlighting a failure to adhere to the facility's policy on CPAP support.
Failure to Ensure Proper Installation and Maintenance of Bed Rails
Penalty
Summary
The staff at the facility failed to ensure the correct installation and maintenance of bed rails for a resident, identified as Resident #49. The resident's bed rails were observed to be loose, allowing movement back and forth several inches, which the resident had reported to the staff. The resident, who was cognitively intact, relied on the bed rails for mobility and positioning due to bilateral above-knee amputations and other significant health conditions, including metabolic encephalopathy, type 2 diabetes, and chronic kidney disease. Despite the resident's notification to the staff about the loose rail, the issue persisted, indicating a lapse in maintenance and monitoring. The facility did not have a policy regarding the use, installation, and monitoring of side rails, which contributed to the deficiency. The Maintenance Director stated that he installed the enabler bars after therapy evaluations and checked them monthly, but did not maintain a log of these checks. The Director of Nursing mentioned that side rail assessments should be reviewed by management and monitored quarterly or when there are changes in the resident's condition. However, there was no formal documentation or consistent process to ensure the safety and security of the bed rails, leading to the deficiency observed during the survey.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 14% error rate during an observed medication pass. This deficiency was identified through two specific incidents involving medication administration errors. In the first incident, a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident with type two diabetes, despite the manufacturer's instructions requiring priming before each use. The resident's blood sugar level was 206 mg/dL, necessitating 4 units of insulin, which was administered without priming the pen. In the second incident, the facility did not adhere to its policy for administering medications through an enteral tube. An LPN crushed and mixed three medications—diltiazem, gabapentin, and oxycodone—before administering them via a percutaneous endoscopic gastrostomy (PEG) tube to a resident. The facility's policy requires each medication to be administered separately with flushing between medications, and there was no physician's order to crush or mix these medications. The resident involved had a diagnosis of chronic obstructive pulmonary disease, respiratory failure, encephalopathy, and dysphagia, and was on a nothing by mouth (NPO) status. Interviews with facility staff, including the Director of Nursing (DON) and the Medical Director, confirmed that the facility's expectations were not met in these instances. The staff acknowledged that insulin pens should be primed before each use and that medications administered through a PEG tube should be given separately with appropriate flushing. The lack of adherence to these protocols contributed to the medication errors observed during the survey.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility staff failed to ensure that all residents were free from significant medication errors when a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident. The resident, who was cognitively intact and had diagnoses including type two diabetes, obesity, dependency on renal dialysis, high blood pressure, and heart failure, was observed receiving insulin injections seven days a week. During an observation, the LPN performed a blood sugar test on the resident, which resulted in a reading of 206 mg/dL, indicating the need for 4 units of sliding scale Novolog insulin. However, the LPN administered the insulin without priming the pen, contrary to the manufacturer's instructions. The manufacturer's instructions for the NovoLog FlexPen, revised in March 2008, specify that the pen should be primed before each injection to ensure proper dosing. The LPN admitted to only priming the insulin pens for their initial use and not for subsequent administrations. Interviews with the Admissions Coordinator and the Director of Nursing (DON) confirmed that the facility's expectation was for staff to prime insulin pens prior to each administration. This oversight in following the correct procedure for insulin administration led to a significant medication error for the resident.
Failure to Provide Timely Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as required by regulations. This deficiency was identified for three residents out of a sample of ten. The facility did not have a policy in place for issuing written transfer notices, which contributed to the oversight. In the case of Resident #30, the transfer notice was not effectively communicated, as the resident and their spouse did not recall receiving any written notification. The notice was initiated on the electronic record system on the day of transfer but was not printed and mailed until 47 days later. Resident #65 experienced a similar issue, with the effective date of the transfer notice being 30 days after the initial transfer and 35 days after a subsequent transfer. The resident's family was informed by phone, but there was no evidence of a written notice being sent in a timely manner. Resident #70 also did not receive a timely written notice, with the effective date being 37 days after the transfer. Interviews with staff revealed a lack of understanding and implementation of the process for sending out written transfer notices. The facility's staff, including LPNs, RNs, and the ADON, were unaware of the requirement to send written notices to families. The Business Office Manager was responsible for sending out the notices but admitted to delays due to their availability. The Administrator confirmed that the facility did not issue written transfer notices, relying instead on verbal communication and monthly logs sent to the Ombudsman. This systemic failure to provide timely written notifications constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Account for Missing Medications and Protect Residents from Misappropriation
Penalty
Summary
The facility failed to keep all residents free from misappropriation when staff could not account for 17 doses of medication, affecting twelve residents. The incident involved a Licensed Practical Nurse (LPN) who was found with multiple pills in their pockets, which were identified as controlled substances such as oxycodone, Lortab, Xanax, and Norco. The police were called, and the LPN was arrested. The facility's Assistant Director of Nursing (ADON) and other staff members conducted a medication count and found discrepancies in the narcotic log, indicating that 17 pills were missing from the count. The missing medications were not documented as administered in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and the narcotic records showed slash marks indicating doses given but not properly accounted for. The facility's policies on abuse, neglect, exploitation, and misappropriation were not followed, as the medications were not signed out correctly, and the investigation process was not thoroughly documented. The Director of Nursing (DON) and other staff members were unaware of the exact number of missing pills and relied on sticky notes and handwritten lists to track the discrepancies. Interviews with staff members revealed that it was not appropriate to put resident medications in staff's pockets or to pop multiple residents' medications at the same time. The facility's failure to account for the missing medications and to follow proper procedures for documenting and investigating the incident resulted in a deficiency in protecting residents from misappropriation of their belongings or money.
Failure to Document and Verify Resident Treatments
Penalty
Summary
The facility failed to ensure all residents' medical records were complete and accurate, as staff did not document whether treatments were completed for four residents and did not follow up on potentially missed treatments. Resident #2, who had multiple diagnoses including cellulitis, multiple sclerosis, and severe sepsis, had orders for various creams to be applied to different parts of the body. On a specific date, the evening doses of these treatments were not documented as administered, and the Assistant Director of Nursing (ADON) noted this without confirming with the residents if the treatments were actually given. Resident #4, who had diagnoses including rhabdomyolysis and chronic pain syndrome, also had orders for skin treatments and blood sugar checks. On the same date, the evening treatments and blood sugar checks were not documented as completed, and the ADON again noted this without verifying with the resident. Similarly, Resident #9, who had type two diabetes and other conditions, had an order for a vaginal cream that was not documented as administered on the same date. Resident #10, diagnosed with COVID-19 and pneumonia among other conditions, had an order for a compression stocking that was not documented as addressed on the same evening. The ADON assumed the treatments were completed by a nurse who had to leave unexpectedly and did not verify with the residents. The Director of Nursing (DON) deferred questions about the missed treatments to the ADON, emphasizing that treatments should be administered as ordered by the physician.
Failure to Administer Pain Medication as Requested
Penalty
Summary
The facility failed to ensure effective pain management for a resident who required such services. Specifically, the staff did not administer the resident's as-needed pain medication when requested, despite the resident showing physical signs of pain. The resident, who had severe sepsis with septic shock, type 2 diabetes mellitus with diabetic chronic kidney disease, and bacteremia, reported experiencing significant pain on the night in question. The resident requested pain medication multiple times from the CNA, who reported the requests to the nurse three times, but the medication was never administered. The resident described the pain as a 10 on a scale of one to 10 and was visibly uncomfortable. The facility's policy on administering oral medications was not followed, as evidenced by the lack of documentation on the MAR/TAR and narcotic records. The ADON, who arrived to cover for a nurse, was unaware of any residents being in pain due to not receiving their medication. The DON confirmed that medications should be administered as ordered by the physician. The failure to administer the pain medication as requested and the lack of proper documentation led to the deficiency noted in the report.
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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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