Life Care Center Of Cape Girardeau
Inspection history, citations, penalties and survey trends for this long-term care facility in Cape Girardeau, Missouri.
- Location
- 365 South Broadview Street, Cape Girardeau, Missouri 63703
- CMS Provider Number
- 265185
- Inspections on file
- 27
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Life Care Center Of Cape Girardeau during CMS and state inspections, most recent first.
Several dependent residents did not receive adequate assistance with hydration, as water was placed out of reach and staff failed to regularly offer or help with fluids. One resident developed severe dehydration and a UTI, requiring hospital care. Staff interviews confirmed inconsistent adherence to hydration protocols, and care plans lacked clear instructions for assisting with drinking.
A resident was found unresponsive and staff initiated CPR and called EMS, despite the hospice record indicating a DNR order and documented consent for no resuscitation. Facility records showed conflicting code status orders, and staff interviews revealed incomplete documentation, lack of verification, and confusion regarding the resident’s wishes. The inconsistent system for documenting and communicating code status led to the initiation of CPR against the resident’s documented DNR preference.
A resident was found unresponsive, and staff initiated CPR based on a report sheet indicating full code status, but stopped after discovering a DNR order in the electronic medical record. Multiple code status changes were documented without proper authorization or communication with the resident, family, or physician. Staff relied on inconsistent sources for code status, leading to confusion and failure to provide basic life support as directed by the resident's wishes and orders.
A resident who was cognitively intact submitted a written request for all medical records and a copy of an internal investigation to the DON, but did not receive access to the records within the required 24-hour period. Staff provided conflicting accounts about the handling of the request, and there was no documentation of follow-up or clarification. The facility lacked a policy for medical records requests, resulting in the resident not receiving timely access.
A resident with a renal transplant did not receive 11 out of 14 scheduled doses of tacrolimus, an immunosuppressant, over a seven-day period due to staff not administering the medication as ordered. Despite timely pharmacy deliveries and the availability of home medication, staff documented the medication as unavailable and did not follow procedures for medication management and communication.
Two residents in an LTC facility experienced unmanaged pain due to the unavailability of prescribed medications, including Norco. Despite having orders for pain assessment and medication administration, the facility ran out of Norco and failed to provide alternatives, leading to severe pain and distress for the residents. Interviews with staff revealed issues with medication supply and communication with the pharmacy.
A resident with multiple health issues did not receive the required physician visits as per facility policy. The resident's family arranged an outside appointment due to the lack of visits, but the facility insisted on using their physician, who had not yet seen the resident. Staff interviews revealed that the new facility physician only saw newly admitted residents, leaving the resident without the mandated care.
A resident requiring a Hoyer lift for transfers was left waiting for transportation after a medical appointment. Due to miscommunication and lack of available transport, the resident was manually transferred into a personal car by staff, causing significant pain and anxiety. The resident was left in a soiled brief for hours, highlighting a failure in ensuring a safe environment free from accident hazards.
A resident with multiple medical conditions and a history of pressure ulcers developed new pressure ulcers due to the facility's failure to conduct timely skin assessments and provide necessary treatment. Despite being at high risk, the resident's care plan lacked specific skin care orders, and staff did not follow the facility's policy for reporting and addressing skin changes. The DON was unaware of the resident's condition, highlighting a breakdown in communication and care processes.
A resident with morbid obesity was not provided with a bariatric bed upon re-admission to the facility, despite weighing 290 lbs and the facility's policy requiring a bariatric bed for residents over 250 lbs. The resident experienced a fall from the standard-sized bed during care, increasing their fear of falling and affecting their mobility. Staff interviews revealed the resident had previously used a larger bed and had requested a bariatric bed, but this was not addressed.
A cognitively impaired resident was sent unescorted in a cab to the ER instead of an ambulance after a medical issue. The resident required assistance with all ADLs and had a cognitive communication deficit. LPN A mistakenly called a cab and did not verify the resident's cognitive status or arrange for an escort. The facility lacked a policy on safe transportation.
Failure to Provide Adequate Hydration Assistance
Penalty
Summary
The facility failed to ensure sufficient fluid intake for residents by not providing fresh, easily accessible water at bedside, and not assisting or cueing residents who required help with hydration. Observations and interviews revealed that multiple residents who were dependent on staff for activities of daily living, including drinking, had water placed out of their reach and did not receive regular assistance or offers of fluids. One resident was observed with cracked and peeling lips, unable to reach or hold a water cup, and reported not being offered water or assistance despite being very thirsty. Another resident, also fully dependent, stated that while water was filled, staff did not offer drinks between meals or at night, and the water cup was placed where the resident could not access it without help. A third resident, who required some assistance with ADLs but could feed themselves, also had water placed far out of reach. Staff interviews confirmed that while there was an expectation for CNAs to offer water during every room entry and bed check, this was not consistently happening. A registered nurse reported having raised concerns about CNAs not performing hydration duties to management multiple times, with no resulting change. The DON was unaware of the hydration issues and stated that staff should be offering fluids regularly to those unable to drink independently. Medical records showed that one resident was sent to the emergency department with severe dehydration and a urinary tract infection, returning with ongoing issues. Care plans for the affected residents indicated their dependence on staff for hydration and risk for dehydration, but observations and interviews demonstrated that these needs were not being met. Documentation and care plans lacked specific instructions regarding assistance with drinking, contributing to the deficiency.
Failure to Ensure Accurate and Consistent Code Status Documentation and Communication
Penalty
Summary
The facility failed to ensure an accurate and consistent system was in place to direct staff when to initiate basic life support, including CPR, in accordance with physician orders and the resident’s advance directives. A resident was found unresponsive and without respirations by staff, who initiated CPR and called emergency medical services (EMS) and hospice. The resident’s facility medical record contained a full code status order, but there was no documentation of the resident’s wishes or consent for this status. In contrast, the hospice record at the facility showed the resident’s consent and an order for do not resuscitate (DNR), with documentation of a conversation reflecting the resident’s choice for DNR. Multiple inconsistencies were found in the documentation and communication of the resident’s code status. The admission paperwork was incomplete, and the baseline care plan did not address the code status. Staff interviews revealed confusion and lack of verification regarding the resident’s wishes, with some staff relying on incomplete or missing documentation in the electronic medical record (PCC) and others referencing the hospice binder, which was not always readily accessible. There was no documented contact with the resident, family, or physician to properly authorize a change from DNR to full code, despite conflicting information between facility and hospice records. Staff statements indicated that the process for documenting and communicating code status was inconsistent, with reliance on verbal reports, incomplete paperwork, and assumptions based on typical hospice practices. The hospice binder, which contained the resident’s DNR documentation, was not always in its designated location, further contributing to the confusion. The lack of a clear, unified, and accessible record of the resident’s code status led to the initiation of CPR against the resident’s documented wishes as per the hospice record.
Failure to Ensure Accurate Code Status Documentation and Communication
Penalty
Summary
The facility failed to ensure an accurate and consistent system was in place to direct staff when to initiate basic life support, including CPR, for a resident. On the morning of the incident, a phlebotomist reported to the nurse's station that a resident would not wake up. An LPN and CNA responded, found the resident pulseless, and checked the report sheet, which indicated the resident was a full code. The LPN began CPR while the CNA checked the electronic medical record, which showed the resident as DNR. CPR was stopped after a few compressions, and 911 was not called. There was confusion among staff regarding the resident's code status due to discrepancies between the report sheet and the electronic medical record. Review of the resident's medical record revealed multiple changes in code status during their stay, including an initial DNR signed by the spouse, a full code signed by the resident upon readmission, and a subsequent DNR order with no documentation or authorization for the change. There was no evidence of contact with the resident, family, or physician to obtain proper authorization for the code status change. The care plan did not reflect the changes in code status, and there was no documentation of the rationale or process for the most recent change. Interviews with staff and the resident's spouse indicated the resident was alert and oriented at the time of the full code order and capable of making their own decisions. Staff reported inconsistent practices for verifying code status, with some relying on outdated report sheets and others on the electronic medical record. The process for changing code status was not followed, as an LPN changed the status based on a phone call without verifying consent or notifying the physician, resident, or family. This lack of a consistent and accurate system led to confusion and failure to provide appropriate life support measures in accordance with the resident's wishes and documented orders.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident timely access to their medical records after a written request was made. The resident, who was cognitively intact and listed as their own responsible party, submitted a written request to the DON for all medical records and a copy of an internal investigation. The request was acknowledged by staff, as documented in a nursing note, but the records were not provided within the required 24-hour timeframe. Interviews with the DON and Administrator revealed confusion and lack of clarity regarding the handling of the request. The DON initially stated the request was sent to the legal department, but later retracted this, admitting there were no emails or documentation of such action. The Administrator and DON both gave conflicting accounts about whether the request included medical records or only the internal investigation, and there was no documentation in the resident's progress notes or facility records to confirm any follow-up or clarification with the resident. The facility did not have a policy regarding medical records requests available for review. Documentation provided by the facility did not mention the medical records request, and staff interviews indicated a lack of consistent process for handling such requests. As a result, the resident did not receive access to their medical records in a timely manner, as required.
Failure to Administer Transplant Medication as Ordered
Penalty
Summary
Facility staff failed to administer tacrolimus, an immunosuppressant medication prescribed for a resident with a history of renal transplant, as ordered by the physician. The resident, who had multiple complex diagnoses including chronic kidney disease, heart failure, and pulmonary hypertension, had a standing order for tacrolimus 1 mg twice daily. Despite the order allowing use of home medication until the pharmacy supply arrived, the medication was not administered for 11 out of 14 scheduled doses over a seven-day period. Documentation showed that the pharmacy delivered the medication as scheduled, but staff progress notes repeatedly indicated the medication was unavailable and on order during this time. Interviews revealed that the resident’s spouse brought in the home supply of tacrolimus, but it was returned the next day with staff stating it was not needed. The Director of Nursing stated that staff are expected to notify the pharmacy when refills are needed and to document the use and storage of home medications. The pharmacy confirmed timely delivery of the medication, and the transplant nephrologist emphasized the importance of not missing doses of tacrolimus for transplant patients. The failure to administer the medication as ordered was not due to pharmacy delay, but rather a breakdown in facility processes for medication management and communication.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in significant discomfort and distress. Resident #1, who had multiple fractures and chronic pain syndrome, was not administered prescribed pain medications, including Norco and acetaminophen, for several days. Despite having orders to assess pain levels and administer medications as needed, the facility ran out of Norco and failed to provide alternative pain management solutions. This led to Resident #1 experiencing severe pain, anxiety, and restricted mobility, impacting their daily activities and quality of life. Similarly, Resident #2, with diagnoses including acute kidney failure and chronic obstructive pulmonary disease, also did not receive their prescribed Norco for pain management. The resident reported increased pain levels, anxiety, and a lack of sleep and appetite due to the unavailability of pain medication. The facility's failure to maintain an adequate supply of pain medication and to provide timely alternatives resulted in Resident #2 experiencing significant discomfort and a decline in their overall well-being. Interviews with facility staff, including the DON and various nurses, revealed that the facility had been experiencing issues with medication supply, particularly with Norco. The facility's emergency medication kit was depleted, and there were delays in obtaining refills from the pharmacy. Despite attempts to contact the pharmacy and physicians for alternative solutions, the residents continued to suffer from unmanaged pain, highlighting a breakdown in the facility's pain management protocols and communication with external providers.
Failure to Ensure Required Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident received the required physician visits as per their policy. Resident #3, who was admitted with multiple diagnoses including falls, acute kidney failure, and chronic pain, did not have any documented visits from a physician or care provider. The facility's policy mandates an initial comprehensive visit within 30 days of admission and subsequent visits every 30 days for the first 90 days, followed by at least every 60 days thereafter. However, Resident #3 had not been seen by the facility physician since admission, leading the family to arrange an appointment with an outside primary care provider. Interviews with facility staff revealed that the previous facility physician left on 11/17/24, and the new physician began seeing some residents on 12/10/24, but only newly admitted ones. The facility's Director of Nursing and Administrator confirmed that residents should be seen by a physician every 30 days for the first 90 days after admission. Despite the family's efforts to have Resident #3 seen by an outside physician, the facility insisted that the resident be seen by the facility physician, which had not occurred by the time of the survey.
Failure to Ensure Safe Transfer for Resident Requiring Hoyer Lift
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for Resident #1, who required a Hoyer lift for transfers due to muscle weakness, reduced mobility, and a history of falling. The resident's medical records indicated a need for maximal assistance with mobility, but there was no documentation of a lift assessment or a comprehensive care plan addressing transfers or mobility concerns. On the day of the incident, the resident attended an appointment at an infusion center and was left waiting for transportation back to the facility for several hours. Due to transportation issues, the Activities Director (AD) and a Licensed Practical Nurse (LPN) attempted to transport the resident back to the facility in the AD's personal car, despite the resident's need for a Hoyer lift. During the transfer, the resident was folded into the car, causing significant pain and anxiety. The resident screamed in pain and was almost dropped during the transfer, which was described as a traumatic experience. The resident also experienced increased knee and back pain and was left sitting in a urine-soiled brief for several hours. Interviews with staff revealed a lack of communication and understanding of the resident's transfer needs. The facility's Transport Coordinator and outside transportation agency had miscommunications, leading to the resident not being picked up as scheduled. The Director of Nursing and Administrator were unaware of the situation until after the incident occurred. The Administrator acknowledged that appropriate accommodations should have been made to ensure the resident's safe transfer, either by using a mechanical lift or providing suitable transportation.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify and treat a facility-acquired pressure ulcer for one resident, who was among five sampled residents. The resident, who had a history of pressure ulcers, was at high risk due to multiple medical conditions, including clostridium difficile, diabetes, end-stage renal disease, neurogenic bladder, morbid obesity, anxiety, depression, and cognitive communication deficit. Despite being at risk, the resident's care plan did not include specific orders for skin care or treatment of wounds, and the resident was noted to be resistive to care, often refusing repositioning and hygiene assistance. The facility's policy required weekly skin assessments and immediate reporting of any skin changes by CNAs to nursing staff. However, the resident's skin integrity assessment on 08/19/24 showed only a blanchable area of redness with no further action documented. The resident continued to refuse dialysis and remained in bed, increasing the risk of pressure ulcers. On 08/21/24, a CNA noticed an open wound on the resident's buttocks but did not recall when it was reported to the LPN, who also did not assess the resident's skin during care. The LPN was unaware of the facility's policy on pressure wounds and did not document or notify the physician for treatment orders. By 08/22/24, the resident had multiple open wounds on the buttocks, including areas with yellow slough and necrotic tissue. The DON was not aware of these wounds and expected the nursing staff to conduct weekly assessments and address the resident's high risk for pressure ulcers. The lack of timely assessment and intervention led to the development and progression of pressure ulcers in the resident.
Failure to Provide Appropriate Bed for Bariatric Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident with morbid obesity, resulting in the resident being placed in a standard-sized bed that was not suitable for their needs. The resident, who weighed 290 lbs and had a history of severe obesity, was admitted to the facility and should have been provided with a bariatric bed according to the facility's policy. However, upon re-admission, the resident was placed in a standard-sized bed, which was too small and did not support their independent mobility. The resident experienced a fall from the bed during incontinent care, which heightened their fear of falling and affected their willingness to move independently. Despite the resident's expressed discomfort and fear, no interventions were added to address the issue. Interviews with staff revealed that the resident had previously used a larger bed and had communicated their need for a bariatric bed, but this request was not fulfilled upon their return from the hospital. The facility's Director of Nursing was unaware of the correct weight requirement for a bariatric bed, mistakenly believing it to be 300 lbs instead of the 250 lbs stated in the facility's policy. This oversight contributed to the resident not being provided with the appropriate bed upon re-admission, leading to the deficiency in accommodating the resident's needs and preferences.
Inadequate Supervision During Resident Transportation
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident during transportation to the emergency room (ER). The resident, who required assistance with all activities of daily living and had a cognitive communication deficit, was sent unescorted in a city cab instead of an ambulance after experiencing a medical issue with a dislodged PICC line. The Director of Nursing was unaware of the resident's cognitive impairment and expected the staff to either call an ambulance or send an escort with the resident. LPN A, who was responsible for arranging the transportation, mistakenly called a cab instead of an ambulance and did not cancel the cab or arrange for an escort. LPN A did not verify the resident's cognitive status before sending them unescorted. LPN B and the facility's nurse practitioner were not informed of the resident's cognitive impairment and agreed that it was not appropriate to send the resident out unattended. The facility lacked a policy on safe transportation, contributing to the oversight.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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