Lincoln County Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Missouri.
- Location
- 1145 East Cherry Street, Troy, Missouri 63379
- CMS Provider Number
- 265433
- Inspections on file
- 21
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lincoln County Nursing & Rehab during CMS and state inspections, most recent first.
Two residents with cognitive impairment and significant mental health and functional needs were subjected to verbal abuse by a housekeeper who yelled, screamed, and used profanity when one resident repeatedly called for help and the other intervened about how the resident was being spoken to. Witnesses, including CNAs and the ADON, reported the housekeeper being in close proximity to a crying resident, shouting obscenities such as “shut the fuck up” and other derogatory language, while the second resident reported being cursed at and called a “bitch” after attempting to defend the first resident. The housekeeper later admitted becoming increasingly angry and "snapping," confirming that he/she yelled and cursed at the resident.
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment, including resident rooms with holes in drywall, incomplete repairs, and persistent dirt and debris on a resident’s bed sheets despite the resident’s request for linen changes. Hallways had strong urine odors, black scuff marks, and sticky floors, and one room contained piles of trash and food on the floor and food stains on bedding and the mattress. Another room had a persistent urine smell with visible puddles of yellow liquid on the floor and under the bed over an extended period. Additional observations showed missing cove base trim, chipped tiles, loose or missing wardrobe handles, cracked windows, missing shower heads, and significant clutter in several rooms that blocked clear pathways. The Maintenance Director described relying on a binder and verbal reports to learn of issues, while the Administrator stated an expectation that residents have a safe, clean, orderly, and comfortable environment.
A resident with vascular dementia became combative during care, resulting in skin tears, as staff failed to identify behavioral triggers, implement non-pharmacological interventions, or update the care plan. Multiple CNAs and LPNs reported not receiving dementia care training, and key information about the resident's behavioral responses to staff of the same gender was not communicated or documented. The facility did not provide a dementia care policy or evidence of staff training.
The facility failed to provide adequate care for several residents, including maintaining comfortable positioning, nail care, and regular bathing. A resident with hemiplegia was left in an uncomfortable position without repositioning, another had unclean fingernails, and three residents did not receive showers as per their care plans. Staff interviews revealed issues with following up on care refusals and maintaining hygiene standards.
The facility failed to provide adequate staffing, resulting in missed showers and inadequate personal hygiene for residents. Despite an assessment indicating the need for 112 CNA hours per day, the facility consistently fell short, impacting resident care. Interviews with staff confirmed the challenges in maintaining basic care due to insufficient staffing.
A LTC facility failed to maintain a safe medication system, with incidents of tampered morphine and Ozempic insulin, and missing oxycodone from the emergency kit. Policies for storing and handling controlled substances were not followed, with improper documentation of narcotic counts and lack of audits contributing to the deficiencies.
The facility failed to maintain safe and appetizing food temperatures, as residents reported receiving cold meals. Observations confirmed that food temperatures were not within the required range, with soup, milk, tea, and ham sandwich all served at improper temperatures. The Dietary Manager was unsure how to maintain hot food temperatures during service, and beverages were not kept on ice as required.
The facility failed to ensure safe serving of hot beverages, resulting in a third-degree burn for a resident. Additionally, the facility did not adequately implement fall prevention interventions for residents at risk, leading to multiple falls and injuries. Furthermore, residents were unsafely transported in wheelchairs without foot pedals, causing their feet to drag on the floor.
A resident with a history of joint pain and surgical amputation experienced unmanaged pain due to the facility's failure to routinely assess pain and offer PRN medication. Despite being on a pain management program, the resident was not informed about available PRN medication and was not offered it when in pain. Staff interviews revealed a lack of awareness and adherence to pain management protocols, with no documentation of pain scores or PRN medication administration.
A resident with mental illness exhibited inappropriate behaviors, including entering another resident's room without pants and making threatening gestures. The facility failed to implement meaningful interventions or update the care plan to address these behaviors, contributing to ongoing issues. Staff interviews revealed inadequate monitoring and response to the resident's actions.
The facility failed to maintain a clean and homelike environment, with observations of unemptied urinals, poor room maintenance, and a shortage of linens. The DON acknowledged the need for regular urinal checks, but this was not consistently done. Maintenance issues included missing paint, holes, and exposed drywall, while the exterior showed signs of neglect. The facility also faced a linen shortage, impacting resident care.
The facility failed to ensure consistent documentation of residents' code status and proper CPR certification among staff. Multiple residents had discrepancies in their code status across various records, leading to potential confusion in emergencies. Additionally, several shifts lacked staff with valid CPR certifications, and the facility did not have policies to address these issues.
The facility employed an unqualified Activity Director who lacked necessary certifications and training, affecting all 67 residents. The director admitted to having no formal training and was the sole member of the activity department, with no resource person available. The Administrator, new to the facility, was unaware of the director's certification status.
The facility failed to provide adequate nursing staff, resulting in insufficient care for residents, including infrequent showers and delayed response to call lights. A resident reported going without a shower for extended periods, while another did not receive restorative therapy due to the absence of a restorative aide. The facility also lacked consistent RN coverage, relying on agency staff who often did not show up, leading to unmet resident needs.
The facility failed to ensure that CNAs, CMTs, LPNs, and RNs demonstrated competencies in essential care areas as outlined in their facility assessment. Training records for two CNAs showed no evidence of education or competencies in the past year, with only new hire training documented. Interviews revealed confusion and lack of responsibility for tracking and implementing training, with no training schedule or documentation available. The facility's attempt to implement a computer software training system was incomplete, and changes in nursing administration contributed to the lack of documentation.
The facility did not maintain the required RN coverage of at least eight consecutive hours a day, seven days a week, potentially affecting all 67 residents. The facility's assessment highlighted the need for such coverage, but reviews of payroll and staffing sheets showed several days in March, April, and May 2024 without RN hours. The interim DON confirmed reliance on agency RNs for weekends, with instances of no-shows.
The facility failed to ensure the Dietary Manager had the necessary certification and skills to manage food and nutrition services. The DM, hired without the required Certified Dietary Manager certification, lacked training and relevant experience. Interviews with staff, including the Registered Dietitian and Director of Nursing, confirmed the absence of certification. The Administrator was unaware of the DM's certification status, despite expecting compliance with federal requirements.
The facility failed to maintain sanitary conditions in its food service operations, with unlabeled food items, unclean equipment, and improper hand hygiene observed. Staff did not adhere to cleaning schedules, and the ice machine lacked an air gap. The Dietary Manager and Administrator were unaware of these issues, indicating a lack of oversight.
The facility failed to use resources effectively, resulting in numerous deficiencies, including lack of infection control logs, inadequate staff training, and reliance on agency staff. There were inconsistencies in medical records, unsanitary dietary services, and medication errors. The facility also failed to provide adequate care for mobility and range of motion, maintain a homelike environment, and ensure resident rights. Additionally, there was insufficient staffing, lack of oversight for administrative tasks, and failure to conduct thorough investigations of abuse allegations.
The facility did not have a current Quality Assurance and Performance Improvement (QAPI) plan or recent meeting minutes, failing to monitor and evaluate system problems. The Interim Administrator, who began in May, confirmed the absence of a QAPI policy and recent activities, with the last meeting minutes dated January 2023. Staff interviews indicated no recent QAPI committee meetings, and only an outdated outline was found.
The facility failed to implement an effective QAA committee, lacking a QA/QAPI policy and recent meeting minutes. The Interim Administrator, who started recently, found no recent QAPI meetings or active Process Improvement Plans. Staff interviews confirmed the absence of recent QAPI activities, despite expectations for a program with quarterly process improvement activities.
The facility did not maintain an active QAPI committee with required members and quarterly meetings. The Interim Administrator, who started recently, found no QAPI policy or recent meeting minutes, with the last notes dated over a year ago. No staff reported being part of a QAPI committee, and the Interim Administrator had not attended any QAPI meetings since starting.
The facility failed to follow infection control protocols, including Enhanced Barrier Precautions for a resident with a catheter, proper sanitization of glucometers during blood glucose monitoring, and maintenance of oxygen and nebulizer equipment. Additionally, the facility lacked a comprehensive water management plan and did not adhere to tuberculosis testing requirements for residents and new employees.
The facility failed to ensure the interim DON, acting as the infection preventionist, completed the required specialized training in infection prevention and control. Although partial module certifications were provided, a full program completion certificate was not available. The MDS coordinator, who had completed the certification, was not involved in the IPCP program at the facility.
The facility failed to provide mandatory training for all staff on its QAPI program, as revealed through interviews and record reviews. The facility's assessment and new employee training documentation did not include QAPI training. Interviews with staff showed a lack of clarity and responsibility for training oversight, with the Director of Nursing unaware of facility-wide training tracking and the RN Training Coordinator not conducting CNA education. The Interim Director of Nursing confirmed the absence of a training schedule, contributing to the deficiency.
The facility failed to maintain an effective infection prevention and control training program, as evidenced by the absence of documented training and competencies for CNAs hired in 2017 and 2023. Despite the facility's assessment requiring infection control education for all nursing staff, new employee training records lacked this component. Interviews revealed confusion over training responsibilities, with no established training schedule or system in place.
The facility failed to provide the required 12 hours of annual in-service education for CNAs, with no evidence of training or competencies documented for two CNAs. Interviews revealed confusion over responsibility for training, with no clear tracking or schedule in place. The facility's assessment lacked dementia and abuse prevention training.
The facility failed to provide comprehensive behavioral health training for all staff, as required by its assessment. Training was limited to nursing staff, excluding others, and new employee training lacked behavioral health components. Interviews revealed confusion over training responsibilities, with key staff unaware of facility-wide training efforts. The facility was attempting to implement a software training system but had no schedule in place.
The facility failed to address and respond to Resident Council concerns, as evidenced by recurring issues in food quality, laundry, and maintenance without documented follow-up. Residents reported dissatisfaction with dietary issues, medication management, and housekeeping. Interviews revealed that department supervisors did not consistently provide responses, and meeting minutes were not shared with residents.
The facility failed to ensure residents could voice grievances without fear of reprisal, as some residents experienced negative staff responses after filing complaints. Additionally, several residents were unaware of the grievance process, and the Social Services Director could not locate the grievance book, indicating poor record-keeping and communication.
The facility failed to complete required significant change in status assessments (SCSA) for three residents after notable changes in their conditions. These changes included increased dependency, cognitive improvements, and new medical needs, which were not documented in updated MDS assessments. The acting MDS coordinator, working part-time, was unaware of the residents' needs, leading to this oversight.
The facility failed to create comprehensive care plans for three residents, leading to deficiencies in addressing their individual needs. A resident's care plan did not reflect their DNR status or refusal of care, while another's plan lacked interventions for cognitive loss and diabetes. Additionally, a third resident's plan omitted details on transfer assistance and oxygen therapy. Staff interviews revealed issues with care plan updates due to staffing and communication problems.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident experienced cognitive decline and medication changes without care plan updates. Another resident had multiple falls due to cognitive impairment, with no care plan revisions for fall risk. A third resident's care plan was not updated after a fall causing injuries and missing hearing aids, impacting communication. Staff confusion over care plan responsibilities contributed to these issues.
The facility failed to adhere to professional standards of practice in medication administration and physician order compliance. Medications were left at the bedside without orders for two residents, necessary lab tests were not conducted for a resident, and another resident received oxygen therapy without a physician's order. Additionally, a resident missed several doses of Victoza due to unavailability and authorization issues.
The facility failed to provide adequate ADL assistance and hygiene care for four residents, leading to unshaven whiskers, improper perineal care, and infrequent showers. Residents with impaired cognition and mobility did not receive necessary grooming and hygiene support, as staff did not follow care plans or provide comprehensive personal care.
The facility failed to provide an adequate activity program for residents, particularly those with dementia, due to a lack of scheduled evening and dementia-specific activities. Observations showed residents with severe cognitive impairments had no involvement in activities, despite care plans indicating preferences. The new, untrained Activity Director struggled to balance responsibilities, leading to frequent cancellations and lack of engagement. The DON acknowledged the absence of specific policies and was unsure of evening and weekend offerings.
The facility failed to provide timely podiatry care for three residents, including two with diabetes, resulting in long and uncomfortable toenails. Despite orders and requests for podiatry consultations, residents had not seen a podiatrist in a long time. Staff interviews revealed issues with obtaining podiatry services and staffing challenges, contributing to the deficiency.
The facility failed to provide restorative services to three residents, impacting their range of motion and mobility. A resident with neck and shoulder limitations did not receive restorative care despite a referral. Another resident with chronic conditions had a restorative plan but no services were provided. A third resident, discharged from therapy, lacked a restorative program in their care plan. Staff interviews revealed the absence of a restorative aide led to the discontinuation of the program.
The facility failed to assess and document bed rail use for several residents, leading to deficiencies in safety and informed consent. A resident did not have a bed rail entrapment assessment or consent before installation, and their care plan lacked mention of bed rails. Another resident used a bed rail for mobility without proper assessment or consent documentation. A third resident's record lacked side rail assessments and physician orders, despite severe cognitive impairment and mobility assistance needs. Staff interviews revealed confusion about responsibilities for assessments and consent.
The facility failed to ensure two nurse aides completed their training and certification within four months of employment. Despite being employed for over six and seven months, neither aide was certified, and there was a lack of clarity and responsibility among staff regarding the tracking and completion of training. The Director of Nursing acknowledged the absence of a specific policy, and various staff interviews highlighted the deficiency in oversight.
The facility failed to provide the required 12 hours of in-service education per year for CNAs, as revealed by interviews and record reviews. Two CNAs lacked documented education hours or competencies, despite the facility's outlined staff education requirements. Interviews with staff indicated confusion over responsibility for tracking and implementing CNA training, contributing to the deficiency.
The facility failed to review or follow up on monthly pharmacy drug regimen recommendations for three residents. Despite the policy requiring comprehensive reviews and reporting, there was no documentation or evidence of addressing the pharmacy consultant's recommendations with the residents' physicians. The director of nursing was unaware of the need to access reports from the pharmacy website, leading to missing documentation and unaddressed recommendations.
The facility failed to comply with regulations for psychotropic medication management, including not limiting PRN orders to 14 days and not attempting gradual dose reductions (GDR) for several residents. The facility's policy lacked specific guidelines for GDRs and 14-day stop dates, and there was a lack of documentation and awareness regarding pharmacy consultant reports, contributing to these deficiencies.
The facility failed to serve food at a safe and appetizing temperature, with multiple residents reporting cold and unpalatable meals. Observations confirmed low food temperatures, such as hashbrowns at 96 degrees Fahrenheit. Despite staff expectations for hot and flavorful meals, the serving process led to significant cooling before consumption.
The facility did not follow its antibiotic stewardship program, which is part of its infection prevention and control efforts. The interim DON, acting as the IPCP, failed to conduct necessary antibiotic surveillance and tracking due to staffing turnover and time constraints. This resulted in a lack of monitoring and documentation of antibiotic use, despite several residents receiving antibiotic treatments.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails for potential entrapment risks, affecting several residents. Observations showed inconsistencies in bed rail positioning, and interviews revealed confusion among staff about responsibilities for measuring entrapment zones. This lack of adherence to policy compromised resident safety.
The facility failed to maintain resident dignity for two residents. One resident felt like a burden due to staff comments during short-staffed periods, while another reported being scolded by the SSD in front of others, which was humiliating. Both residents were cognitively intact and expressed concerns about the treatment they received.
A facility failed to notify a resident and their representative when the resident's trust account balance exceeded the Medicaid resource limit. The resident's account balance was over the limit, but no notice was given to the responsible party. Interviews revealed a lack of awareness and communication regarding the balance, with the BOM unaware of the excess and the regional fund manager relying on the bookkeeper and family to monitor the balance.
A resident alleged that a CNA slapped them, leading to a fall and a skin tear. The facility failed to conduct a thorough investigation as per its policy, lacking interviews with key staff and other residents. The DON and Administrator admitted that necessary steps were not taken to complete the investigation.
A facility failed to accurately code the MDS for a resident with severe cognitive impairment and multiple diagnoses, leading to discrepancies in documented falls and mobility status. The part-time MDS coordinator completed assessments without full knowledge of residents, relying on staff input and missing interdisciplinary meetings. The DON was unsure of the assessments' accuracy due to the coordinator's limited presence.
Failure to Protect Two Residents From Verbal Abuse by Housekeeper
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from verbal abuse by a staff member, specifically a housekeeper. The facility’s abuse policy states that each resident will be free from abuse, including verbal and mental abuse, and that no abuse or harm of any type will be tolerated. Despite this, on 03/30/26, a housekeeper yelled, screamed, and cursed at two residents while in their shared room. The Assistant Director of Nursing (ADON) heard shouting and cursing, went to the room, and observed the housekeeper shouting obscenities at one of the residents. One resident involved had Alzheimer’s disease, required substantial to maximal assistance with dressing, and needed partial to moderate assistance with bed mobility and was dependent on staff for transfers. The resident’s care plan documented assistance needs with activities of daily living and mobility due to weakness and cognitive impairment. This resident reported that the housekeeper told him/her to “shut up” and used profanity, including the words “fuck,” “damn,” and “shit,” which made the resident feel bad. Multiple staff witnesses, including CNAs and the ADON, described the housekeeper being very close to this resident, yelling, and using phrases such as “Shut the fuck up bitch. I’m trying to do my job,” and “Shut the fuck up,” while the resident was crying and shouting in the room. The second resident involved had a serious mental illness, dependency needs for emotional and physical care, a history of domestic violence in prior marriages, a mood disorder with depression and anxiety, a diagnosis of major depressive disorder with a prior suicide attempt, poor coping skills, a history of trauma, and moderate cognitive impairment. This resident stated that the housekeeper began yelling at the first resident when the first resident was calling for help, and when the second resident told the housekeeper not to talk that way, the housekeeper cursed at him/her, called him/her a “bitch,” and said “damn you.” The second resident reported feeling upset that the housekeeper “picked on” him/her because he/she could not defend himself/herself. The housekeeper’s own written statement confirmed that he/she became increasingly angry at the first resident’s shouting, “snapped,” and screamed and cursed at the resident, corroborating the accounts of verbal abuse toward the residents.
Failure to Maintain Safe, Clean, and Orderly Environment and Housekeeping Standards
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, including adequate housekeeping and maintenance services. Surveyors observed an occupied resident room with a hole in the drywall under the PTAC unit and visible white spackle on the wall, indicating incomplete repair. In another occupied room, dirt and debris were repeatedly observed on a resident’s bed sheets over multiple days, and the resident stated they wanted staff to change the sheets. On one hallway, surveyors noted a strong urine odor, black scuff marks along the corridor, and a sticky floor, and on another hallway, a strong urine odor was repeatedly noted on several days. In an additional occupied resident room, surveyors observed piles of trash and food on the floor, including an open can of food with a dirty spoon, dirty napkins/Kleenex, food pieces, and food wrappers along the wall and under the bed. Food pieces and stains were also present on the resident’s bedding and mattress. Another occupied room had a persistent urine smell and visible puddles of yellow liquid on the fall mat, floor, and under the bed, which were observed as dried or fresh at different times over two days. These conditions showed that spills and soiled areas were not cleaned promptly as outlined in the facility’s floor-cleaning policy. Further observations over two days revealed multiple maintenance and clutter issues throughout resident rooms and common areas. Several rooms had missing cove base trim, chipped floor tiles, holes in drywall, loose or missing wardrobe handles, cracked windows, and missing shower heads in bathrooms. Some resident rooms contained large areas of accumulated clothes, papers, decorations, boxes, trash, food, and beverages stacked on tables, floors, and refrigerators, leaving no clear pathways around beds or between beds and walls. The soiled utility room had a non-functioning light and missing floor tile, and the lobby guest bathroom had discolored flooring and rust stains on the sink and drain. The Maintenance Director reported that staff encouraged residents to keep clutter-free spaces and that he relied on a binder at the nurses’ station and verbal reports to learn of maintenance issues, and the Administrator stated she expected residents to have a safe, clean, orderly, and comfortable environment.
Failure to Identify and Address Dementia-Related Behaviors and Provide Staff Training
Penalty
Summary
The facility failed to provide appropriate care and services to maintain the highest practical well-being for a resident with vascular dementia. Staff did not identify or document triggers that led to the resident's aggression and combativeness, nor did they implement or document non-pharmacological interventions to address these behaviors. During an incident, staff continued to provide incontinence care and transferred the resident using a sit-to-stand lift while the resident was actively combative, resulting in the resident sustaining skin tears. The care plan was not updated to reflect the resident's behavioral responses or to provide individualized interventions related to dementia care. Multiple staff interviews revealed that several CNAs and LPNs had not received dementia care training upon hire and lacked direction on how to manage the resident's aggressive behaviors. Some staff were unaware of how to access care plans, and others relied on verbal reports to learn about resident care needs. Staff also reported that the resident was only aggressive with certain staff members, particularly those of the same gender, but this information was not communicated to facility leadership or reflected in the care plan. The psychiatric nurse practitioner was not informed of the resident's behavioral issues, and the care plan coordinator acknowledged that the care plan should have been updated after the incident. The facility did not provide a dementia care policy when requested, and there was no evidence that staff had received or understood dementia care training. The lack of communication, training, and individualized care planning contributed to the failure to address the resident's behavioral symptoms and ensure staff were equipped to manage dementia-related behaviors safely and effectively.
Deficiencies in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and services for several residents, leading to deficiencies in maintaining comfortable positioning, nail care, and bathing. Resident #4, who was admitted post-stroke with flaccid hemiplegia, was observed in an uncomfortable position in bed with legs hanging off the foot of the bed and was not repositioned by staff despite expressing discomfort. The resident was also left with a towel to clean up urine spills, indicating inadequate incontinence care. Resident #10, who required setup assistance for personal hygiene, was found with brown debris under the fingernails, which the resident was unaware of and upset about. This indicates a lack of attention to personal hygiene needs by the staff. Additionally, the facility's policy on nail care, especially for diabetic residents, was not adhered to, as there was no evidence of licensed nurses cutting the resident's fingernails. Residents #1, #5, and #14 did not receive showers as per their care plans, which specified twice-weekly showers. The records showed significant gaps between showers, and interviews with residents and staff confirmed that showers were often missed due to staffing issues. Resident #5's roommate noted that showers were infrequent, and Resident #14 reported not receiving showers twice a week. Staff interviews revealed that when residents refused showers, there was no consistent follow-up to ensure they received care, contributing to the deficiency in maintaining hygiene standards.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, particularly in the area of bathing. The facility's assessment indicated that with an average census of 60 residents, 112 certified nurse aide (CNA) hours per day were required. However, a review of the facility's daily staffing sheets from late December to mid-January showed consistent shortfalls in CNA hours, with deficits ranging from 7 to 44 hours per day. This staffing inadequacy directly impacted the care provided to residents, as evidenced by missed showers and inadequate personal hygiene. Three residents were specifically noted to have been affected by the staffing shortages. One resident, who required moderate assistance with showering, did not receive showers twice a week as scheduled, with gaps of up to 11 days between showers. Another resident, who preferred showers to bed baths, was only offered showers sporadically, with refusals noted but also significant gaps between offered showers. A third resident, who required supervision for bathing, also experienced long intervals between showers, sometimes up to nine days. Interviews with staff, including nurse aides and licensed practical nurses, confirmed the staffing issues, with reports of missed showers and difficulty in providing basic care such as hair brushing and incontinence care. The Director of Nursing and other administrative staff acknowledged challenges in filling open slots on the nursing schedule and were unaware of the specific staffing requirements outlined in the facility assessment. The administrator expected sufficient staffing to provide quality care but was uncertain if the responsible staff knew the required hours per discipline.
Medication Tampering and Documentation Failures in LTC Facility
Penalty
Summary
The facility failed to maintain a safe and effective medication system, as evidenced by several incidents involving tampered medications and improper documentation of narcotic counts. Morphine prescribed for two residents was found to have unusual smells, indicating tampering, and a card of oxycodone was missing from the facility's emergency medication kit. Additionally, an Ozempic insulin pen for another resident was tampered with and replaced with a different type of insulin. These incidents highlight significant lapses in medication security and monitoring. The facility's policies for storing and handling medications, particularly controlled substances, were not adequately followed. Controlled substances were not consistently stored under double lock and key, and the required narcotic counts at shift changes were not properly documented. Interviews with staff revealed that medication counts were often not conducted due to the absence of available personnel to perform the task together, leading to discrepancies in the controlled substance shift change log. The facility's failure to audit medication carts and the Stat Safe emergency medication kit contributed to the deficiencies. The consultant pharmacist discovered the missing oxycodone during a routine visit, and it was noted that a nurse could access the Stat Safe without a witness. The lack of oversight and adherence to policies for medication administration and documentation resulted in multiple instances of medication tampering and missing narcotics, compromising resident safety.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature, as observed during a survey. The facility's policy requires hot foods to be served at no less than 120 degrees Fahrenheit and cold foods at no greater than 40 degrees Fahrenheit. However, during meal service, residents reported receiving cold meals, and observations confirmed that food temperatures were not maintained within the required range. Specifically, a test tray showed soup at 118 degrees Fahrenheit, milk at 62 degrees Fahrenheit, tea at 60 degrees Fahrenheit, and ham on a sandwich at 52 degrees Fahrenheit. These temperatures were below the facility's standards for hot foods and above the standards for cold foods. Interviews with residents revealed consistent complaints about receiving cold meals, particularly when meals were served in their rooms. The Dietary Manager acknowledged the issue, noting that the soup was initially at 165 degrees Fahrenheit before service but was unsure how to maintain the temperature during service. Additionally, beverages were not kept on ice as required, contributing to the improper temperatures. The Administrator confirmed that beverages should be kept on ice and meals should be served in a timely manner to ensure proper temperatures.
Deficiencies in Hot Beverage Service, Fall Prevention, and Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in a third-degree burn for a resident. The resident, who was cognitively intact but had limited range of motion, was served hot water in a large Styrofoam cup, which was placed out of reach. As the resident attempted to pull the overbed table closer, the cup tipped over, spilling hot water onto the resident's leg. The facility did not have a policy for hot liquid service, and staff training did not include instructions on placing trays or allowing drinks to cool before serving. The facility also failed to implement and modify fall prevention interventions for residents at risk of falls. One resident with a history of falls and moderate cognitive impairment experienced multiple falls, resulting in injuries such as a dislocated shoulder and lacerations. Despite these incidents, the resident's care plan was not updated to address the fall risk adequately. Another resident with severe cognitive impairment and a history of falls was not provided with a care plan that addressed their fall risk, leading to multiple falls and injuries. Additionally, the facility did not safely transport residents in wheelchairs, as staff pushed residents without foot pedals, causing their feet to drag on the floor. This practice was observed with multiple residents, and staff were unaware of the location of the foot pedals. The facility's policy on wheelchair use did not address the importance of using foot pedals during transport, contributing to the unsafe transportation of residents.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of joint pain, surgical amputation, and phantom leg pain. The resident was on a pain management program that included scheduled and PRN opioids, but the facility did not routinely assess the resident's pain as ordered. The resident frequently experienced pain that interfered with daily activities and expressed agitation and difficulty sleeping due to pain. Despite having PRN pain medication available, the resident was not informed of this option and was not offered additional medication when complaining of pain. Interviews with the resident revealed that their pain was never controlled, and they were unaware of the availability of PRN medication. Observations showed the resident in distress, rocking back and forth in their wheelchair, and expressing frustration about their unmanaged pain. The facility's medication administration record (MAR) lacked documentation of PRN medication administration and pain scores, indicating a failure to follow physician orders for pain assessment every shift. Staff interviews highlighted a lack of awareness and adherence to pain management protocols. Certified Medication Technicians (CMTs) responsible for the resident's care did not document pain scores or offer PRN medication, as they believed the resident was simply agitated and did not request it. The Director of Nursing (DON) acknowledged the expectation for staff to follow physician orders and assess pain, but was unaware of the resident's ongoing pain issues and inability to sleep.
Failure to Provide Appropriate Behavioral Interventions for Resident with Mental Illness
Penalty
Summary
The facility failed to provide appropriate person-centered and individualized treatment and services to a resident with mental illness, resulting in multiple incidents of inappropriate behavior. The resident, who had a history of schizoaffective disorder, major depressive disorder, anxiety disorder, and a history of trauma, exhibited behaviors such as entering another resident's room without pants, lighting a cigarette indoors, and making threatening gestures towards other residents. Despite these behaviors, the facility did not implement meaningful interventions or ensure the resident received services to address these behaviors. The resident's care plan was not adequately updated to address ongoing inappropriate sexual behaviors and aggressive actions towards peers. The facility's interventions were insufficient, as evidenced by the resident's continued inappropriate actions, including touching other residents inappropriately and attempting to choke a roommate. The facility's lack of a comprehensive behavior management policy and failure to implement non-pharmacological interventions contributed to the deficiency. Interviews with staff revealed that the resident's behaviors were often triggered by urinary tract infections, yet the facility's response was limited to encouraging fluid intake. The facility did not consistently monitor the resident's interactions with peers, and staff were not always present to redirect the resident during negative behaviors. The facility's failure to provide a structured environment and consistent routines, as recommended in the resident's PASRR II assessment, further contributed to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of poor housekeeping and maintenance practices. In several resident rooms, urinals were not emptied or replaced as per physician orders, leading to unpleasant odors. The Director of Nursing acknowledged that urinals should be checked and emptied regularly by staff, but this was not consistently done. Additionally, the facility lacked a homelike environment policy, and the housekeeping department was short-staffed, contributing to the inadequate cleanliness and maintenance of resident rooms. Numerous observations revealed significant maintenance issues throughout the facility. Resident rooms had walls with missing paint, holes, and exposed drywall, while bathroom fixtures were stained and in disrepair. The facility's exterior also showed signs of neglect, with rotted trim boards, missing paint, and loose siding. The maintenance director admitted to being aware of some issues but was unable to address them due to budget constraints and lack of resources. The housekeeping supervisor noted that vents were cleaned monthly, but the buffer machine needed for floor maintenance was broken, further hindering cleaning efforts. The facility also faced a shortage of linens, impacting the ability to provide adequate resident care. Linen carts and closets were often empty or contained insufficient supplies, forcing residents to wait for bed changes or use their own linens. The laundry supervisor reported a decrease in available linens, suspecting that agency staff might be discarding them. Despite notifying the previous administrator about the shortage, no action was taken to address the issue. The current administrator acknowledged the lack of a linen policy and was unaware of any requests for additional linens from the supplier.
Inconsistent Code Status Documentation and CPR Certification Deficiencies
Penalty
Summary
The facility failed to ensure systems were in place to clearly document residents' code status and communicate this information to direct care staff. This deficiency was identified for multiple residents, where inconsistencies were found between the residents' face sheets, care plans, physician order sheets (POS), paper charts, and the facility's 24-hour daily nursing reports. For instance, one resident's face sheet did not indicate a code status, while their care plan and POS showed a full code status, yet the 24-hour daily nursing report indicated a DNR status. Such discrepancies were prevalent across several residents, leading to potential confusion about whether to perform CPR in emergencies. The facility also failed to ensure that a staff member with the required CPR certification was scheduled for each shift. The survey revealed that several shifts lacked staff with valid CPR certifications, and some staff members' CPR certifications did not meet the requirements for basic life support (BLS) for healthcare providers. Interviews with staff members highlighted a lack of clarity and consistency in identifying residents' code status, with some relying on outdated or incorrect documentation. Additionally, the facility did not have policies regarding staff CPR certification, scheduling for CPR coverage, or code status documentation. The Director of Operations confirmed the absence of such policies, and the Director of Nursing acknowledged the inconsistencies in code status documentation and the lack of verification of agency staff CPR credentials. This lack of policy and oversight contributed to the deficiencies observed during the survey.
Unqualified Activity Director Lacks Certification and Training
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program, affecting all 67 residents. The current Activity Director had not completed an approved activity professional training program and lacked both state certification and certification in therapeutic recreation or activities. The facility was unable to provide job title responsibilities and qualifications for the Activity Director, only providing a job description for an assistant activity director. The employee list confirmed that the department head was the Activity Director, yet her file showed no relevant certifications. Interviews revealed further deficiencies in the activity program. The Activity Director admitted to having no formal training in activities and split her time between activities and resident transportation. She was the sole member of the activity department and had no resource person to assist her. She also expressed a lack of knowledge regarding appropriate activities for residents with dementia. The Director of Nursing indicated that the administrator was responsible for ensuring staff certifications. However, the Administrator, who was new to the facility, was unaware of the Activity Director's certification status and expected a certified director to oversee and train her until certification was obtained.
Staffing Shortages and Inadequate Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the lack of routine showers and timely response to call lights for certain residents. Specifically, Resident #61 did not receive regular showers, leading to poor personal hygiene and body odor. The resident expressed dissatisfaction with the infrequency of showers and the lack of staff to change bed sheets. Additionally, Resident #41 reported delays in receiving assistance, including waiting an hour for help and not receiving restorative therapy due to the absence of a restorative aide. The facility also did not maintain the required staffing levels, including the absence of a Registered Nurse (RN) for eight consecutive hours a day, seven days a week. The facility's staffing records showed multiple days without RN coverage, and the Director of Nursing (DON) confirmed that the facility relied heavily on agency staff, who often did not show up for work. This staffing shortage affected the delivery of care, as residents reported delays in receiving medications and assistance with activities of daily living. Furthermore, the facility's restorative nursing program was discontinued after the restorative aide left, leaving residents without necessary therapy. The therapy director and DON confirmed that the program was halted due to the lack of trained staff. The facility's failure to maintain adequate staffing and provide necessary care and services as outlined in the facility assessment contributed to the deficiencies observed during the survey.
Failure to Ensure Staff Competency and Training
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents, as outlined in their facility assessment. The assessment, updated on 5/20/24, specified that all Certified Nurse Assistants (CNAs), Certified Medication Technicians (CMTs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) were required to demonstrate competencies in various areas such as activities of daily living, mobility, fall prevention, bowel and bladder care, skin integrity, mental health, medication and pain management, infection control, management of medical conditions, therapy, special care needs, nutrition, and person-centered care. However, the facility did not provide evidence of education, testing, or return demonstrations for these competencies. The report highlighted specific deficiencies in the training records of two CNAs. CNA C, hired on 12/5/17, and CNA PP, hired on 4/17/23, both lacked documentation of education hours or competencies in the past year. The only training documented for both was their new hire training, which did not include any competencies. Interviews with the Interim Director of Nursing, Social Service Director (SSD), RN Training Coordinator/MDS Coordinator, and Business Office Manager revealed a lack of clarity and responsibility regarding the tracking and implementation of training and competencies for CNAs and other staff. The Interim Director of Nursing admitted that the facility was attempting to implement a computer software training system, but it had not been accomplished. There was no training schedule in place, and the documentation of training and competencies was either missing or could not be located. The facility had undergone changes in nursing administration, which contributed to the confusion and lack of documentation. The report indicates a systemic failure in maintaining and verifying staff competencies, which is crucial for ensuring the well-being of residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, which had the potential to affect all 67 residents. The facility's assessment, updated on May 20, 2024, indicated the necessity of RN coverage for eight hours daily. However, a review of the facility's RN payroll and agency staffing sheets revealed multiple instances in March, April, and May 2024 where there was no evidence of RN hours, specifically on March 4, 9, 10, and 31, April 19, and May 18, with insufficient hours on April 5. During an interview, the interim Director of Nursing stated she was the only full-time RN, and the facility relied on agency RNs for weekends, but there were occasions when agency RNs did not show up.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to fulfill the responsibilities of the food and nutrition services department. The DM, hired on January 23, 2023, lacked the required certification as a Certified Dietary Manager, a federal requirement for long-term care facilities. Additionally, there was no evidence of certification as a certified food service manager, national certification for food service management, or documentation of an associate's or higher degree in food service management or hospitality. The DM also did not have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. The only certification present was a State Food Safety Food Protection Manager Certification, which does not meet the dietary manager certification requirements. Interviews with facility staff revealed that the DM had not received any training related to the position and had only attended a food safety course. The Registered Dietitian, who visits the facility monthly, confirmed that the DM was not certified. The Director of Nursing acknowledged the lack of certification, stating that it was the administrator's responsibility to ensure staff certifications. The Administrator expressed an expectation for the DM to be certified and, if not, to be supervised by a certified Dietary Manager or Dietitian until certification was obtained. However, the Administrator admitted to not being aware of the DM's certification status due to his short tenure at the facility.
Sanitation and Hygiene Deficiencies in Food Service Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, as observed during a survey. Staff did not label and date opened food items in the kitchen refrigerator, including sandwiches and pudding, which is against the facility's food storage guidelines. Additionally, the ice machine was not properly cleaned, with scaly material and slime observed, and lacked an appropriate air gap at the drain, which is necessary for sanitary conditions. The Maintenance Director was unaware of the missing air gap and the Dietary staff were behind on checking items for labeling and dating. The kitchen and food preparation areas were found to be in unsanitary conditions, with slime and debris in the steam table, oil and debris on the sneeze guard, and a buildup of oily material on various kitchen surfaces and equipment. The cleaning schedules were not adhered to, as evidenced by the presence of dust, debris, and oily material on kitchen hoods, fire suppression systems, and other surfaces. Dietary staff admitted to not completing cleaning tasks due to time constraints, and the Dietary Manager was unaware of the extent of the cleanliness issues due to a recent absence. Improper hand hygiene and glove use were also observed, with staff failing to wash hands before putting on gloves and using the same gloves for multiple tasks. Staff entered the kitchen without hairnets and handled food without washing hands, which is against the facility's handwashing and glove use guidelines. The Dietary Manager and Administrator were not fully aware of these issues, indicating a lack of oversight and adherence to sanitary practices in the facility's food service operations.
Facility Fails to Use Resources Effectively, Leading to Multiple Deficiencies
Penalty
Summary
The administration of the facility failed to effectively use its resources to ensure the highest practicable well-being of its residents. Observations during the survey period revealed numerous deficiencies, including the absence of infection control logs, lack of yearly staff education on dementia care, abuse, and neglect, and failure to provide required training hours for certified nursing assistants. The facility also lacked an organized Quality Assurance and Performance Program (QAPI) and relied entirely on agency staff for licensed nursing positions, with no permanent licensed nursing staff hired. Additionally, there were inconsistencies in residents' cardiopulmonary resuscitation status across medical records, unsanitary dietary services, and medication administration errors. Further deficiencies included inadequate management of foot care, failure to prevent decline in mobility and range of motion, inconsistent protective oversight, and insufficient supplies such as linens. The facility did not consistently provide assistance with activities of daily living, follow infection control measures, or offer an activities program that met the needs of all residents. There was a lack of proper certification for key staff roles, failure to ensure resident rights, and grievances were not being addressed. The facility also failed to provide oversight for various administrative tasks, such as completing Advance Beneficiary Notices and notifying residents about trust account balances. The physical environment was not maintained, and there was insufficient staffing to meet residents' needs. Additionally, the facility did not conduct thorough investigations of abuse allegations or ensure timely and accurate assessments. Pharmacy reviews were not being received or followed up on, and the facility had experienced significant turnover, relying heavily on agency staffing.
Lack of QAPI Plan and Implementation
Penalty
Summary
The facility failed to establish and implement a Quality Assurance and Performance Improvement (QAPI) plan to monitor and evaluate system problems, as evidenced by the absence of a current QAPI policy or recent meeting minutes. The facility, with a census of 67, did not provide a QAPI policy when requested by the state agency. The last available QAPI meeting minutes were dated January 2023, and no current, facility-specific QAPI plan was found in the provided binder. The Interim Administrator, who started on May 7, 2024, confirmed that the facility lacked a QAPI policy, recent minutes, or completed QAPI information. Interviews with current staff revealed that no one recalled recent QAPI committee meetings, and the Interim Administrator only found an outline of what to do, which he was unsure was current. He expected the facility to have a QAPI program with process improvement activities meeting quarterly with appropriate team members.
Failure to Implement Effective QAA Committee
Penalty
Summary
The facility staff failed to implement an effective Quality Assessment and Assurance (QAA) committee to address and resolve identified concerns. The facility, with a census of 67, did not provide a Quality Assurance (QA)/QAPI policy when requested. A binder labeled QAPI, reviewed on May 23, 2024, contained meeting minutes last dated January 2023. The Interim Administrator, who began on May 7, 2024, confirmed that the facility lacked a QAPI policy and recent meeting minutes. Interviews with current staff revealed no recent QAPI meetings or active Process Improvement Plans. The Interim Administrator expected the facility to have a QA/QAPI program with quarterly process improvement activities involving appropriate team members.
Lack of Active QAPI Committee and Meetings
Penalty
Summary
The facility failed to maintain an active Quality Assurance and Process Improvement (QAPI) committee with the required members and quarterly meetings. The facility, with a census of 67, did not provide documentation of a QAPI policy or recent meeting minutes. The last available QAPI meeting notes were dated over a year ago. The Interim Administrator, who started on 5/7/24, confirmed that no QAPI policy or recent minutes were available and that no staff reported being part of a QAPI committee. The Interim Administrator expected the QAPI program to include the Administrator, Director of Nursing, several floor staff, department heads, medical director, pharmacist, and dietitian, meeting at least quarterly. However, he had not participated in any QAPI meetings since his tenure began.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols for multiple residents, leading to several deficiencies. For Resident #20, who had an indwelling urinary catheter, staff did not follow Enhanced Barrier Precautions (EBP), as they were unaware of what EBP entailed and did not use gowns during care. This resident had a history of urinary tract infections and returned from the hospital with antibiotics, yet the staff did not implement the necessary precautions to prevent further infections. Additionally, the facility did not follow proper infection control practices during blood glucose monitoring for several residents. The staff failed to sanitize the glucometer appropriately and did not place it on a clean surface after use. This oversight occurred repeatedly across different residents, indicating a systemic issue with the procedure for blood glucose monitoring. The facility also neglected to maintain proper infection control regarding oxygen and nebulizer equipment. Oxygen tubing was not changed as ordered, and nebulizer equipment was not cleaned according to facility policy. Furthermore, the facility did not have a comprehensive water management plan to prevent Legionella, and there were lapses in tuberculosis testing for both residents and new employees, with some tests not being administered or documented correctly.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) completed the required specialized training in infection prevention and control. The interim Director of Nursing (DON) was serving as the IP after the departure of the previous DON and assistant director of nursing (ADON). Although the interim DON claimed to have completed the Infection Prevention Control Program (IPCP), the facility was unable to provide a certificate of completion for the entire program, only partial module certifications were available. This deficiency affected all 67 residents in the facility. Additionally, the facility's policy required the selection of an Antibiotic Stewardship Champion (ASC) who would be responsible for implementing and maintaining the antibiotic stewardship program, with certification through the CDC. However, the MDS coordinator, who had completed the IPCP certification, was only employed part-time for MDS assessments and had not been involved in the IPCP program at the facility. The MDS coordinator provided her certificate to the facility for potential future assistance, but no direct involvement in the IPCP was noted at the time of the survey.
Failure to Provide Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training for all staff on its Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through interviews and record reviews, revealing that the facility did not include QAPI training in its new employee training or ongoing staff education. The facility's assessment, updated on 5/20/24, outlined various staff education and competencies but did not address QAPI training. Additionally, the new employee training documentation lacked any mention of QAPI training, focusing instead on topics like resident rights, abuse prevention, and company policies. Interviews with facility staff highlighted a lack of clarity and responsibility regarding training oversight. The Director of Nursing was unaware of any facility-wide training tracking beyond new hire training. The Social Service Director, who previously tracked CNA and NA training, no longer did so, and the RN Training Coordinator/MDS Coordinator stated she did not conduct CNA education or competencies. Furthermore, the Business Office Manager confirmed the absence of QAPI training records for specific employees. The Interim Director of Nursing acknowledged the facility's attempt to implement a computer software training system, which had not yet been accomplished, and confirmed the absence of a training schedule. This lack of structured training and oversight contributed to the facility's failure to ensure all staff received mandatory QAPI training, as required.
Deficiency in Infection Control Training Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control training program for its staff, as evidenced by the lack of documented training and competencies in the employee education files of two Certified Nurse Assistants (CNAs) hired in 2017 and 2023. The facility's assessment indicated that all CNAs, Certified Medication Technicians (CMTs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) were required to undergo education and return demonstrations to assess their abilities in infection prevention and control. However, the new employee training records reviewed did not include infection control training, despite the facility's stated requirements. Interviews with various staff members revealed a lack of clarity and responsibility regarding the tracking and implementation of infection control training. The Director of Nursing was unaware of who was responsible for facility-wide training beyond new hires, while the Social Service Director and RN Training Coordinator/MDS Coordinator both indicated they did not track or conduct CNA training or competencies. Additionally, the facility was in the process of implementing a computer software training system, but this had not yet been accomplished, and there was no established training schedule in place.
Deficiency in CNA Training and Competency Documentation
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) received the required 12 hours of in-service education annually. This deficiency was identified through interviews and record reviews, which revealed that two CNAs, hired on different dates, did not have any documented evidence of education hours or competencies in the past year. The facility's assessment, updated in May 2024, outlined various staff education and competencies but did not address dementia training or annual abuse and neglect prevention training. Interviews with facility staff highlighted a lack of clarity and responsibility regarding the tracking and provision of CNA training. The Director of Nursing initially indicated that the Social Service Director was responsible for tracking training hours and competencies, but the Social Service Director stated that the RN Training Coordinator was handling CNA training. However, the RN Training Coordinator confirmed that she did not conduct any CNA education or competencies, nor did she perform annual training for CNAs. Further interviews revealed that the facility was attempting to implement a computer software training system, but this had not been accomplished. The Interim Director of Nursing mentioned that there was no training schedule in place and that while some training documentation was completed earlier in the year, changes in nursing administration led to uncertainty about the current status of training records and staff attendance.
Deficiency in Behavioral Health Training for Facility Staff
Penalty
Summary
The facility failed to maintain a comprehensive training program for all staff, specifically lacking in behavioral health care and services training. The facility's assessment, updated in May 2024, outlined the need for staff education in managing mental health and behavioral issues, including psychiatric symptoms, cognitive impairments, and other psychiatric diagnoses. However, the training was only identified for nursing staff, excluding other facility staff. The new employee training program also did not include behavioral health training, which was a requirement according to the facility assessment. Interviews with various staff members, including the Director of Nursing, Social Service Director, and RN Training Coordinator, revealed a lack of clarity and responsibility regarding the tracking and implementation of training programs. The Director of Nursing was unaware of any facility-wide training beyond new hire training, and the Social Service Director no longer tracked CNA training. The RN Training Coordinator confirmed that she did not conduct CNA education or competencies, nor did she handle annual training for all employees. The Business Office Manager confirmed the hire dates of CNAs but did not have additional training information. The Interim Director of Nursing acknowledged the absence of a training schedule and the ongoing attempt to implement a computer software training system.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to consistently address and respond to concerns brought forth by the Resident Council, as evidenced by the lack of documentation and follow-up on issues raised during council meetings. The facility's grievance protocol, which outlines the responsibilities of the Social Services Director (SSD) and the administrator in handling grievances, was not effectively implemented. The Resident Council Meeting Minutes from February, March, and April 2024 highlighted recurring issues such as inadequate food quality, unresolved laundry problems, and maintenance concerns, with no documented follow-up or resolution. Interviews with residents and staff revealed that department supervisors did not consistently provide responses to the Resident Council's questions or recommendations, and meeting minutes were not shared with the residents. Residents expressed dissatisfaction with various aspects of their care, including dietary issues, medication management, and housekeeping. Specific grievances included bland and improperly cooked food, missing laundry items, and insufficient housekeeping staff. Additionally, maintenance issues such as broken beds and wheelchairs, and the need for air conditioner filter replacements were reported. Despite these ongoing concerns, the facility did not maintain a consistent process for addressing and resolving grievances, as the Activities Director did not follow up for responses from department supervisors, and the administrator's expectations for timely responses were not met.
Failure to Ensure Safe Grievance Process
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal. Two residents expressed concerns about the negative response from staff after filing grievances. One resident reported that staff made derogatory comments after a grievance was filed, and another resident expressed fear of retaliation, indicating a lack of a safe environment for voicing concerns. Additionally, the facility did not adequately inform residents about the grievance process. Several residents were unaware of how to file a grievance or that they could file directly with the state agency. This lack of information suggests that the facility did not effectively communicate the grievance procedures to its residents, which is a critical component of ensuring residents' rights are upheld. The Social Services Director, responsible for managing grievances, was unaware of certain grievances and could not locate the grievance book, which was found damaged and unreadable. This indicates a failure in maintaining proper records and oversight of the grievance process, further contributing to the deficiency in handling resident grievances appropriately.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for three residents within the required 14-day period after a significant change in their condition was identified. This deficiency was observed in a review of 24 sampled residents. The facility did not perform the necessary assessments to document changes in the residents' physical or mental conditions, which impacted multiple areas of their health status and required an interdisciplinary review and revision of their care plans. For Resident #54, the facility did not complete an SCSA despite significant changes in the resident's condition, including a decline in cognitive and physical abilities, the need for oxygen therapy, and a shift to comfort care only. The resident, who previously exhibited independence in certain activities, became dependent on staff for all care and was placed on oxygen therapy. These changes were not reflected in an updated MDS, indicating a failure to reassess and adjust the care plan accordingly. Resident #42 experienced a significant increase in cognitive ability, a decrease in pain, and changes in mobility and restraint use, yet the facility did not complete an SCSA to document these improvements. Similarly, Resident #52 showed increased dependency in activities of daily living, a rise in incontinence and falls, and new diagnoses, but the facility failed to conduct an SCSA. The acting MDS coordinator, who was only present part-time, admitted to not being fully aware of the residents' needs and not completing the necessary assessments, contributing to the oversight.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents, leading to deficiencies in meeting their individual needs. For Resident #20, the care plan did not reflect the resident's preferred Do Not Resuscitate (DNR) status, despite it being documented in the resident's out-of-hospital DNR form. Additionally, the care plan lacked documentation of the resident's repeated refusals of catheter and peri-care, which were noted in multiple progress notes. Interviews with staff revealed that the resident often refused care from certain staff members, yet this was not addressed in the care plan. Resident #68's care plan was found lacking in addressing the resident's cognitive loss/dementia and diabetes, despite these conditions being documented in the resident's medical records and physician orders. The resident's admission and quarterly Minimum Data Set (MDS) assessments indicated severe cognitive impairment and diabetes, yet the care plan did not include any problems, goals, or interventions related to these diagnoses. This oversight suggests a failure to incorporate critical health information into the care planning process. For Resident #4, the care plan did not include necessary details on how the resident was to transfer, despite requiring substantial assistance for transfers as indicated in the MDS. Furthermore, the care plan did not document the resident's need for oxygen therapy or the discontinuation of restorative nursing services, which were noted in the physician orders. Interviews with facility staff revealed a lack of clarity and responsibility in updating care plans, with the Director of Nursing acknowledging that care plans were not being updated due to staffing issues and lack of communication.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the comprehensive care plans for three residents, leading to deficiencies in their care. Resident #17 experienced a significant decline in cognitive function, increased assistance needs, and changes in medication, including the addition of an antidepressant and pain management drugs. Despite these changes, the resident's care plan was not updated to reflect the new cognitive status, medication regimen, or the removal of an indwelling urinary catheter. Observations showed the resident's condition had changed, yet the care plan remained outdated. Resident #52 had multiple falls, some resulting in injuries, due to severe cognitive impairment and attempts to assist a family member who was also a resident. The care plan did not address the resident's fall risk or the need for increased supervision and assistance. Despite several falls and changes in the resident's condition, including increased assistance needs and the use of a walker, the care plan was not revised to include these critical interventions. Resident #42's care plan was not updated after improvements in transfer, ambulation, continence, and cognition. The resident experienced a fall resulting in a dislocated shoulder and facial lacerations, yet the care plan did not reflect these injuries or the need for increased pain management. Additionally, the resident's missing hearing aids were not addressed in the care plan, impacting communication with staff. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, contributing to the deficiencies.
Medication Administration and Physician Order Compliance Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice, as evidenced by several incidents involving multiple residents. For Resident #38, medications were left at the bedside without a physician's order permitting self-administration. The resident had various medications, including an inhaler and pain medication, left unattended, which the resident claimed to use as needed. The Certified Medication Technician (CMT) acknowledged that medications should not be left at the bedside unless ordered by a physician, yet the resident's medications were found unattended. Resident #59 also had medications left at the bedside without the appropriate order. The resident was unsure about the medication left and when it was brought to them. The Licensed Practical Nurse (LPN) and CMT both confirmed that the resident should not have medications left at the bedside, yet the medication was found and later taken by the resident without supervision. This indicates a lapse in following the facility's medication administration policy. Additionally, the facility failed to obtain necessary laboratory tests and maintain medication availability. Resident #1 did not have a required Dilantin level drawn, and the Director of Nursing (DON) could not explain how the order was missed. Resident #25 was on oxygen therapy without a physician's order, and Resident #45 experienced multiple days without receiving the prescribed Victoza due to unavailability and issues with prior authorization. These incidents highlight a pattern of non-compliance with physician orders and facility policies, leading to potential risks for the residents involved.
Inadequate ADL Assistance and Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) to four residents who were unable to perform these tasks independently. Resident #4, with severely impaired cognition and dependent on staff for personal hygiene, was observed with unshaven whiskers despite expressing a preference for a clean-shaven appearance. The resident's care plan indicated a need for assistance with ADLs due to dementia progression, yet staff did not meet these needs as evidenced by the resident's unkempt appearance. Resident #26, who was incontinent of bowel and bladder and at high risk for urinary tract infections, did not receive proper perineal care. Observations showed that CNAs failed to clean all necessary areas during incontinence care, leaving the resident's skin in contact with urine and feces. The care plan required assistance with toileting and hygiene, but the staff did not adequately perform these tasks, compromising the resident's hygiene and comfort. Resident #28, with moderately impaired cognition and limited mobility, did not receive comprehensive personal care. The CNA did not clean all areas during perineal care, and the resident was left with unkempt hair and dried matter around the eyes. Additionally, Resident #61, who required assistance with bathing and personal hygiene, went extended periods without showers, leading to body odor and long facial hair. The facility's policies lacked specific guidelines on the frequency of showers and personal grooming, contributing to the deficiencies observed.
Inadequate Activity Program for Dementia Residents
Penalty
Summary
The facility failed to design an activity program that met the needs, interests, and well-being of its residents, particularly those with dementia. Observations and interviews revealed that there were no scheduled evening activities or activities specifically tailored for dementia residents. The activity calendar showed limited weekend activities, primarily consisting of bingo and devotionals, with no evidence of one-on-one activities or engagement for residents with cognitive impairments. Resident #22, diagnosed with dementia and severely impaired cognitive skills, was observed to have no involvement in activities despite a care plan that encouraged socialization and participation in favorite activities. Similarly, Resident #44, also with severe cognitive impairment, expressed the importance of religious services and music but had no documented activity assessments or participation. Resident #52, with a diagnosis of dementia, had preferences for reading, music, and outdoor activities, yet there was no evidence of activity engagement or assessments in their medical record. Interviews with staff and residents highlighted systemic issues in the activity program. The Activity Director, who was new and untrained, struggled to balance her responsibilities between activities and transportation, resulting in frequent cancellations and lack of enthusiasm. The Director of Nursing acknowledged the lack of specific policies for activities and was unsure of the evening and weekend offerings. The facility's failure to provide adequate activities for dementia residents and ensure consistent programming contributed to the deficiency.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for three residents, including two with diabetes, in a sample of 24 residents. Resident #36, who has congestive heart failure, end-stage kidney disease, and diabetes, had orders from a dialysis clinic to have their toenails trimmed, which were not followed. Observations showed that the resident's toenails were long, uneven, and causing discomfort. Despite multiple reminders from the dialysis clinic, the resident had not seen a podiatrist in a long time. Resident #9, diagnosed with heart failure and requiring assistance with personal hygiene, had an order for a podiatry consult that was not fulfilled. The resident expressed a desire to see a podiatrist, indicating it had been a long time since their last visit. Similarly, Resident #34, who is diabetic, had not seen a podiatrist for over a year despite having an order for a podiatry evaluation. The resident expressed a need to see a podiatrist due to their diabetic condition. Interviews with facility staff revealed systemic issues in obtaining podiatry services. CNA W stated that CNAs were not allowed to clip toenails for diabetic residents, and a list for the podiatrist had been started six weeks prior without a visit occurring. LPN R mentioned difficulties due to thick toenails and staffing issues, while the social services director and the Director of Nursing acknowledged problems with securing a foot care provider, noting that a new podiatrist had been contracted but had not yet seen the residents.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide restorative services to three residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. Resident #28 had limitations in neck and shoulder range of motion and required assistance with activities of daily living (ADLs). Despite a referral for restorative nursing to maintain upper body strength and standing tolerance, there was no evidence of restorative services being provided. Observations showed the resident was unable to assist with upper body movements and required maximum assistance for transfers. Resident #41, with diagnoses including chronic kidney disease and diabetes mellitus, had a restorative plan for upper and lower extremity strengthening. However, the resident did not receive any restorative nursing minutes, and there was no evidence of services being provided. The resident expressed a desire for restorative nursing but noted the facility lacked the staff to provide it. Resident #68, diagnosed with cerebrovascular disease and vascular dementia, was discharged from skilled therapy with a plan for a restorative program. Despite this, the resident's care plan did not include restorative nursing, and there was no documentation of such services. Observations indicated the resident required substantial assistance for mobility and transfers. Interviews with staff revealed the facility's restorative aide had been terminated, and no replacement had been hired, leading to the discontinuation of the restorative nursing program.
Deficiencies in Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for several residents, leading to deficiencies in safety and informed consent. For Resident #15, the facility did not complete a bed rail entrapment assessment or obtain consent before installing bed rails. The resident expressed a preference for the left bed rail to be raised instead of the right, which was not addressed by the facility. The resident's care plan did not include any mention of bed rails, despite the resident using them for safety and comfort. Resident #39 also experienced a lack of proper assessment and documentation regarding bed rail use. The resident used a 1/8 bed rail for bed mobility, but there was no record of a bed rail assessment, entrapment assessment, or informed consent in the medical record. The resident's care plan mentioned the use of a U-bar for bed mobility but did not address the necessary assessments or consent. Similarly, Resident #44's medical record lacked side rail assessments, physician orders, and documentation of interventions attempted before bed rail installation. The resident had severe cognitive impairment and required assistance with mobility, yet the care plan did not address bed rail use or entrapment risk. Interviews with facility staff revealed confusion about responsibilities for bed rail assessments and consent, with the MDS Coordinator and nursing department cited as responsible parties.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides, referred to as NA NN and NA OO, completed a nurse aide training program within four months of their employment. NA NN was employed as a nurse aide starting on November 13, 2023, and NA OO on October 3, 2023. At the time of review, neither had been certified as a nurse aide according to the state NA registry, despite being employed for over six and seven months, respectively. The Director of Nursing acknowledged the lack of a specific policy regarding nurse aide certification, stating that the facility followed regulatory guidance. Interviews with various staff members revealed a lack of clarity and responsibility regarding the tracking and completion of nurse aide training. The Social Service Director mentioned that she no longer kept track of CNA or NA training, and the RN Training Coordinator/MDS Coordinator stated she only assisted with NA training at another facility. The Business Office Manager confirmed the hire dates and provided training records, but there was no evidence of certification completion within the required timeframe. This lack of coordination and oversight led to the deficiency in ensuring timely certification of nurse aides.
Deficiency in CNA In-Service Education Hours
Penalty
Summary
The facility failed to ensure that each Certified Nurse Assistant (CNA) received the required 12 hours of in-service education per year, as mandated by their individual performance review. This deficiency was identified through interviews and record reviews, which revealed that two CNAs, who had been employed for over a year, did not have any documented evidence of education hours or competencies in the past year. The facility's assessment outlined specific areas where staff education and competencies were to be demonstrated, including activities of daily living, mobility, fall prevention, and other critical care areas. However, the records for CNA C and CNA PP showed only new hire training with no subsequent competencies or education hours documented. Interviews with various staff members, including the Director of Nursing, Social Service Director, and RN Training Coordinator, highlighted a lack of clarity and responsibility regarding the tracking and implementation of CNA training and competencies. The Social Service Director stated that she no longer tracked CNA training, while the RN Training Coordinator claimed not to conduct any CNA education or competencies. The Interim Director of Nursing mentioned attempts to implement a computer software training system, which had not been accomplished, and acknowledged the absence of a training schedule. This lack of coordination and documentation led to the deficiency in meeting the required in-service education hours for CNAs.
Failure to Review and Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the monthly pharmacy drug regimen recommendations were reviewed or followed up on for three residents. The facility's policy required a consultant pharmacist to perform a comprehensive review of each resident's medication regimen and clinical record at least monthly, with findings and recommendations reported to the director of nursing, attending physician, medical director, and administrator. However, for Resident #8, there was no documentation of the pharmacy consultant's reports with recommendations, nor any evidence that the facility addressed these recommendations with the resident's physician, despite multiple entries in the progress notes indicating the need to 'see report.' Similarly, for Resident #13, the pharmacy consultant's reports were not documented in the resident's medical record, and there was no evidence that the facility addressed the recommendations with the resident's physician. The resident had a complex medical history, including bipolar disorder, conversion disorder with seizures, and major depressive disorder, and was on multiple medications. Despite the pharmacy consultant's notes indicating the need to 'see report,' there was no follow-up or documentation of the recommendations being addressed. For Resident #20, the facility also failed to document and address the pharmacy consultant's recommendations. The resident had a history of chronic pain syndrome, major depressive disorder, and generalized anxiety disorder, among other conditions. The pharmacy consultant recommended a gradual dose reduction for Alprazolam, but there was no response from the resident's physician, and the facility did not follow up on this recommendation. The director of nursing was unaware that the pharmacy recommendations had to be printed from the pharmacy website and did not have access to the reports until the survey date, resulting in missing documentation and unaddressed recommendations.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for several residents. Specifically, the facility did not limit PRN (as needed) psychotropic medication orders to 14 days unless a physician documented the necessity for an extension. This was observed in the cases of three residents who had ongoing PRN orders without appropriate stop dates or physician justification for continuation beyond the 14-day limit. Additionally, there was a lack of documentation indicating that these medications were administered, suggesting a failure in monitoring and managing the medication orders effectively. Furthermore, the facility did not attempt or document gradual dose reductions (GDR) for residents on psychotropic medications, nor did they provide clinical justification for maintaining current dosages. This was evident in the cases of several residents who were prescribed medications such as Trintellix, Rexulti, Zoloft, Lexapro, Wellbutrin XL, and alprazolam. The medical records lacked evidence of GDR attempts or contraindications, indicating a failure to adhere to guidelines that require regular evaluation and adjustment of psychotropic medication dosages. The facility's policy on antipsychotic medication use did not specifically address the requirements for GDRs or 14-day stop dates, contributing to the deficiencies observed. Interviews with the Director of Nursing (DON) revealed a lack of awareness and access to pharmacy consultant reports, which are crucial for identifying and addressing medication management issues. The absence of these reports and the failure to act on pharmacy recommendations further highlight the facility's shortcomings in ensuring safe and appropriate use of psychotropic medications.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at a safe and appetizing temperature. Multiple residents reported that their meals were often served cold, with some describing the food as terrible, overcooked, or soggy. Observations confirmed these complaints, with test trays showing food temperatures well below acceptable levels. For instance, green beans were served at 114 degrees Fahrenheit, hashbrowns at 96 degrees, and fried potatoes at 90.3 degrees, all of which are below the standard for hot food service. Additionally, the food was described as bland or overly salty, further indicating a lack of attention to flavor and seasoning. The dietary staff, including the Dietary Manager and Registered Dietician, were interviewed and expressed expectations that meals should be served hot and prepared in a way that conserves nutritive value, flavor, and appearance. However, the process of serving meals, particularly to residents eating in their rooms, took an extended period, resulting in food cooling significantly before being consumed. Despite the staff's stated expectations, there was a clear disconnect between these expectations and the actual service provided, as evidenced by the residents' complaints and the observed food temperatures.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, which is a critical component of its infection prevention and control program. The program's policy outlined responsibilities for the infection preventionist (IP) or designee, including auditing clinical assessment documentation at the time of antibiotic prescription, ensuring completeness of antibiotic prescribing documentation, and monitoring antibiotic initiation. Additionally, the policy required tracking of C. difficile and antibiotic-resistant infections, as well as maintaining a monthly infection/antibiotic control log and line listing. However, during the survey, it was found that these protocols were not being followed. The interim Director of Nursing (DON), who had been serving as the infection prevention and control professional (IPCP) due to staffing turnover, admitted to not having conducted any antibiotic surveillance logs or tracking of antibiotic use since taking over the role. This inaction led to a lack of monitoring and documentation of antibiotic use in the facility. Medical record reviews revealed that several residents were treated with antibiotics, but there was no evidence of the required oversight and documentation as per the facility's policy. The interim DON acknowledged the failure to implement the antibiotic stewardship program due to time constraints and staffing issues.
Failure to Inspect Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment risks for residents using these assistive devices. This deficiency was identified during a review of 24 sampled residents, including three specific residents who used bed rails or assist bars. The facility's policy on bed rail use, which includes guidelines from the FDA on potential zones of entrapment, was not adhered to, as there was no documentation of regular inspections being conducted. Resident #15, who is at risk for falls due to poor balance and impulsivity, had a care plan that did not document regular inspections of their bed frame, mattress, and bed rails. Observations showed inconsistencies in the positioning of the bed rails, and the resident expressed a preference for the left rail to be raised, which was not accommodated. Similarly, Resident #39, who requires substantial assistance for mobility, had a 1/8 bed rail in use, but there was no evidence of inspections for entrapment risks. Resident #44, with severe cognitive impairment and a high fall risk, also had a 1/8 bed rail in use without documented inspections. Interviews with facility staff revealed a lack of clarity regarding responsibilities for measuring entrapment zones. The Maintenance Supervisor was unaware of his responsibility to measure these zones, and the Director of Nursing acknowledged that staff had not been conducting monthly measurements as required. This lack of communication and adherence to policy contributed to the facility's failure to ensure the safety of residents using bed rails.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide care that enhanced resident dignity for two residents. One resident, who was cognitively intact and required assistance with personal hygiene and dressing, reported feeling like a burden due to the nursing staff's comments when the facility was short-staffed. The resident mentioned that staff would respond to call lights with remarks such as 'What do you want now?' and 'Let's get this done. I have several things to do,' which made the resident feel uncomfortable and burdensome. Another resident, also cognitively intact, reported that the Social Service Director (SSD) did not treat residents with dignity and respect. The resident described being scolded by the SSD in front of others, which was humiliating and embarrassing. The resident also observed the SSD scolding and talking down to other residents, which was intimidating. Despite reporting this behavior to a previous Director of Nursing, the current Director of Nursing was unaware of any concerns with the SSD.
Failure to Notify Resident of Trust Fund Balance Exceeding Medicaid Limit
Penalty
Summary
The facility failed to notify a resident and/or their representative when the resident's trust account balance reached $200 less than the Supplemental Security Income (SSI) resource limit, which is a requirement for residents receiving Medicaid benefits. This deficiency was identified for one resident in a sample of 24, with the facility census being 67. The resident in question had a family member designated as the responsible party and Durable Power of Attorney for financial and health care decisions. The resident's trust fund account balance exceeded the Medicaid resource limit of $5,726.00, reaching $5,887.24 on April 30, 2024, and $5,748.24 on May 20, 2024. However, there was no evidence that the facility provided notice to the resident or their legal representative about the account balance exceeding or approaching the Medicaid eligibility limit. Interviews with the Business Office Manager (BOM) and the regional resident fund manager revealed a lack of awareness and communication regarding the resident's trust fund balance. The BOM admitted to not realizing the resident's balance exceeded the limit and had not sent a notice to the resident's Durable Power of Attorney. The regional resident fund manager indicated reliance on the facility's bookkeeper to monitor the trust fund balances and mentioned that the responsibility also lay with the family to monitor the balance. This oversight in monitoring and notifying the appropriate parties led to the deficiency identified in the report.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation as per its policy. A resident reported that a CNA slapped them in the face during care, which was not adequately investigated. The facility's policy requires immediate investigation, including interviews with involved staff and residents, but this was not fully executed. The incident involved a resident who alleged that a CNA slapped them, causing them to fall and sustain a skin tear. The resident reported the incident to the police through the administrator. The facility's documentation lacked interviews or statements from key staff members who were on duty during the incident, and there were no interviews with other residents who received care from the alleged staff member. Interviews with staff revealed gaps in the investigation process. The DON and Administrator acknowledged that interviews with other residents and staff were not conducted, and no educational measures on abuse were initiated. The facility's failure to follow its abuse investigation protocol resulted in an incomplete investigation of the reported incident.
Inaccurate MDS Coding and Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, as required by the Resident Assessment Instrument (RAI) manual. The MDS assessments did not accurately reflect the resident's status, particularly in terms of falls and mobility. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and spinal issues, experienced several falls that were not properly documented in the MDS. The assessments failed to include both injury and non-injury falls, and there were discrepancies in the resident's mobility status, as the resident was observed to always be in a wheelchair, contrary to the MDS documentation. The acting MDS coordinator, who was only present at the facility part-time, admitted to completing the MDS assessments without full knowledge of the residents. She relied on staff input and was not present during interdisciplinary team meetings, which contributed to the inaccuracies in the assessments. The Director of Nursing acknowledged that the MDS assessments were expected to be completed according to the RAI manual but was unsure of their accuracy due to the part-time status of the MDS coordinator. The facility's failure to ensure accurate MDS coding highlights a lack of comprehensive assessment and coordination among staff. The resident's frequent falls and the discrepancies in their documented mobility and fall history indicate a significant oversight in the assessment process. This deficiency underscores the importance of having knowledgeable and consistent staff involved in the MDS assessment process to ensure accurate and up-to-date resident information.
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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