Livingston Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chillicothe, Missouri.
- Location
- 939 East Birch, Chillicothe, Missouri 64601
- CMS Provider Number
- 265621
- Inspections on file
- 26
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Livingston Manor Care Center during CMS and state inspections, most recent first.
A resident with dementia, impaired cognition, generalized muscle weakness, and wheelchair dependence, who was care planned for potential verbal and physical aggression, was physically abused by a CNA during a meal when the CNA struck the resident’s hand, forcibly pushed the resident’s hands into their lap twice, and threw a bowl of food onto the table after the resident slapped at the CNA. Video footage confirmed the actions and showed the resident grimacing. The facility’s abuse policy prohibited staff-to-resident abuse and required staff education, but the CNA’s file showed incomplete abuse-prevention and dementia-care training, and staff who heard slapping sounds and were aware of the CNA’s prior comments about self-defense did not immediately report suspicion of abuse to nursing leadership.
The facility failed to follow its abuse reporting policy by not immediately notifying law enforcement after a staff member was suspected of physically abusing a resident with dementia, poor coordination, generalized muscle weakness, and dependence for ADLs. Security footage showed the resident, seated in a wheelchair in the dining room, slap at a CNA, who then slapped the resident’s hand, twice forcefully shoved the resident’s hand toward the lap, and threw a bowl of food onto the table. A NA heard a slapping sound and later, after overhearing dietary staff discuss the CNA’s comments about defending themself from residents, reported the suspicion of abuse to the Administrator. The Administrator did not contact law enforcement at the time of the allegation, stating she believed it was unnecessary because the resident had no injury, despite facility policy requiring immediate reporting of suspected abuse to law enforcement.
Surveyors found unsanitary conditions in the kitchen and food storage areas, including food debris, dirty surfaces, uncovered and undated food items, and improper storage practices. Staff interviews confirmed that food should be dated and stored properly, and the kitchen kept clean, but these standards were not consistently followed.
The facility did not ensure that posted menus matched the meals served, nor did it provide or communicate menu choices to residents with severe cognitive impairment. Staff failed to ask residents or families about meal preferences, and there was confusion among staff about responsibilities for menu updates and communication, resulting in residents not receiving meals as planned or having access to alternate options.
A resident with a history of behavioral issues struck another resident in the head during a dining room altercation. Despite care plan interventions and the facility's abuse policy requiring increased supervision after such incidents, staff did not implement closer monitoring for the resident who initiated the abuse until several days later, resulting in a failure to protect residents from physical abuse.
Staff failed to follow infection control protocols during wound care for two residents, including not performing hand hygiene with glove changes, not consistently wearing protective gowns when required, and handling personal items and treatment supplies with contaminated gloves. PPE was not readily available near resident rooms, and Enhanced Barrier Precautions were not properly implemented or ordered by a physician. The care plans did not address EBP, and staff interviews revealed gaps in knowledge and training regarding these precautions.
The facility failed to maintain professional standards in food safety and sanitation, including improper handwashing, incomplete food temperature checks, and inadequate food storage practices. Staff were observed using unsanitary handwashing techniques, and food temperature logs were incomplete, with some items not checked before serving. Additionally, personal items were improperly stored near food, and dishwashing practices were not consistently followed.
The facility failed to maintain resident dignity and privacy by applying clothing protectors without consent, standing while assisting residents with meals, and conducting medical procedures in the dining room. Residents were left exposed without privacy curtains, and blood sugar checks and insulin administration were done publicly, contrary to facility policy.
The facility failed to address and resolve grievances raised by residents during council meetings, as shown by the lack of documentation and follow-up on issues such as meal preferences, staff introductions, and cleanliness. Residents reported irregular and non-private meetings without reviews of their rights, and staff admitted to not providing feedback on concerns. The Administrator acknowledged the need for feedback, highlighting a gap between policy and practice.
The facility failed to provide residents access to their personal funds after business hours and on weekends, as confirmed by interviews with residents and staff. The facility's policy states that residents should manage their funds, but access is limited to office hours only.
The facility failed to manage residents' personal funds properly, resulting in negative balances for several discharged residents. The Business Office Manager was unaware of the reasons for these negative balances and did not know the source of funds when petty cash was negative. Interviews revealed confusion about fund refunds and a lack of proper financial oversight.
The facility did not periodically inform residents of their rights, as required. The policy on resident rights lacked guidance on communication timing, and four residents reported not receiving education on their rights. Meeting minutes from March to May 2024 showed no review of resident rights, and the Activity Director confirmed not discussing them during meetings.
A resident with severe cognitive impairment had conflicting resuscitation orders in their medical records, with the care plan indicating Do Not Resuscitate (DNR) status while the physician order sheet showed both DNR and full code entries. The facility failed to ensure clarity and consistency in the resident's advance directives, as required by their policy.
The facility failed to provide the correct Medicare forms to residents, using outdated and incorrect forms for three residents. This oversight involved the use of expired ABN forms and incorrect SNF ABN forms, contrary to the facility's policy requiring current CMS-approved forms. The Administrator admitted to the error during an interview.
The facility failed to maintain a clean and comfortable environment for its 29 residents, with issues such as uncomfortable temperatures, dust accumulation, and strong odors. Observations revealed broken infrastructure, including chipped tiles and missing blinds. Staff interviews highlighted challenges in obtaining necessary supplies and maintaining cleanliness. Resident council minutes showed ongoing complaints about dust and odors, with no documented resolutions, contributing to the facility's deficiencies.
The facility failed to ensure residents were informed about their grievance rights and did not provide accessible grievance forms. Residents were unaware of how to file grievances, lacked access to forms, and did not know the grievance officer. Staff interviews revealed inconsistencies in form accessibility, with forms located in areas inaccessible to residents, requiring staff assistance. The Administrator admitted forms were not posted or accessible, and there was no means for anonymous reporting.
The facility failed to implement its Abuse and Neglect policy by not completing required background checks and screenings for staff before they began working with residents. This affected multiple staff members, including LPNs and CNAs, as checks like the Family Care Registry and Employee Disqualification List were either delayed or not conducted. Interviews revealed that the Business Office Manager lacked access to necessary systems to perform these checks, and the Corporate Administrator acknowledged the oversight.
The facility failed to conduct comprehensive assessments for two residents, resulting in incomplete MDS documentation regarding their preferences for routine and activities. Both residents had severe cognitive impairments, and there was no evidence of interviews with family or staff to determine their preferences. The care plans included various interventions, but these were not effectively implemented, and the residents had minimal engagement in activities. The facility lacked a policy on comprehensive assessments and had not held care meetings since administrative changes.
The facility failed to complete Level 1 PASARR screenings for two residents before admission, as required by Medicaid rules. One resident had an incomplete Level 1 screening despite a diagnosis of unspecified psychosis and use of antipsychotic medication. Another resident, with severe cognitive impairment and multiple psychotropic medications, lacked a Level 1 PASARR in their medical record. The responsibility for PASARR completion was with the understaffed Social Services department.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical and psychosocial needs. A resident's care plan omitted oxygen use despite a physician's order, another lacked an advance directive despite being a full code, and a third did not address side rail use despite cognitive impairment. Staff interviews revealed care plan meetings had not occurred due to administrative changes, and the facility lacked a social services or MDS coordinator.
The facility failed to follow professional standards by not obtaining necessary physician's orders for blood sugar checks and side rails, and by incorrectly setting a low air loss mattress for a resident. Additionally, documentation for medications and treatments was incomplete, indicating lapses in care.
The facility failed to provide adequate personal hygiene care for several residents, including a resident who was not shaved as per preference, another who did not receive oral care or have their face and hands washed, and a third who received improper perineal care. Observations and staff interviews confirmed these deficiencies, highlighting a lack of adherence to the facility's care policies.
The facility failed to provide meaningful daily activities for residents, impacting their physical, mental, and psychosocial well-being. Several residents, including those with severe cognitive impairments, were minimally engaged in activities over several months. The Activity Director lacked formal training and faced budget constraints, while staff had no dementia-specific training, leading to inadequate activity provision.
The facility failed to lock wheelchair brakes during transfers for three residents, all of whom were dependent on staff for mobility and required mechanical lifts. Observations showed that CNAs did not lock the brakes while using the Invacare hydraulic lift 9805P, and the facility's policy did not specify this requirement. Interviews revealed a lack of training and awareness among staff, as confirmed by the DON.
The facility failed to provide proper respiratory care for residents requiring oxygen therapy. One resident had an incorrect oxygen setting and an empty humidified water bottle, while another had undated oxygen tubing. Staff interviews revealed confusion about responsibilities for changing tubing and filling humidified bottles, contrary to facility policy.
The facility failed to assess and manage the use of bed rails for two residents, leading to potential safety risks. One resident was not assessed for entrapment risk, and no physician's order was obtained for side rails. Another resident, with severe cognitive impairment, was not assessed for alternatives to side rails. Staff interviews revealed improper procedures and documentation regarding bed rail use.
The facility did not comply with the requirement to have an RN on duty for eight consecutive hours per day, seven days a week. Staffing records showed multiple instances of non-compliance across several months. The Administrator and DON acknowledged the requirement and the lapses in coverage.
A facility reported a 32% medication error rate, affecting four residents. Errors included improper administration of nasal spray, failure to provide Seroquel Rub for psychosis, and incorrect insulin pen use. Medications were crushed against guidelines, and insulin pens were not primed or cleaned properly.
The facility failed to ensure proper insulin administration, resulting in significant medication errors for two residents. An LPN did not prime insulin pens before administering insulin, contrary to facility policy. The LPN acknowledged the oversight, and the DON confirmed the correct procedure was not followed.
The facility failed to ensure proper labeling and storage of medications, with a resident's Flonase nasal spray lacking a pharmacy label and medications left at the bedside of two residents. Additionally, medication drawers were found unclean, and staff were unaware of cleaning responsibilities.
The facility failed to ensure the Dietary Manager (DM) had the necessary certification and skills to manage food and nutrition services. Despite being in the role since April 2021, the DM was still enrolled in a certification program, which would not be completed until November 2024. Interviews confirmed that the DM should have been certified, indicating non-compliance with staffing requirements.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of TB screening for newly hired staff and the absence of hand sanitizer on the memory care unit. Employee files showed no TB tests were completed for six sampled staff members, contrary to facility policy. Additionally, hand sanitizer dispensers were empty due to supply issues, with staff confirming the absence of hand sanitizer since March. The Director of Nursing was unaware of the shortage, indicating a communication gap in infection control management.
The facility failed to ensure that the call light system was accessible for residents, with observations showing call lights out of reach or improperly placed. This affected residents with severe cognitive impairments and dependencies on staff for personal care. Despite maintenance checks, some rooms lacked functioning call light strings, and staff interviews revealed inconsistent practices in ensuring accessibility.
A facility failed to complete a discharge summary for a resident at the time of their planned discharge. The resident, who had intact cognitive skills and was independent in several activities of daily living, was diagnosed with seizure disorder, anxiety, depression, high blood pressure, and PTSD. Despite the facility's policy requiring a comprehensive discharge summary, the resident's medical record lacked this documentation, as confirmed by the Administrator.
The facility employs an Activity Director who lacks the necessary qualifications and certifications to oversee the activity program. Despite being in the role since 2017, the director has not completed an approved training program and has no specific training in dementia activities. Interviews with facility administrators revealed a lack of knowledge about the certification requirements for this position.
A resident with severe cognitive impairment and a stage 3 pressure ulcer did not receive ordered pressure ulcer care, including the use of pressure off-loading boots and weekly skin assessments. Observations showed the resident without boots in bed, and staff interviews revealed non-compliance with care orders. The facility lacked a specific pressure ulcer policy, contributing to the deficiency.
A facility failed to provide proper catheter care, leading to potential risk of UTIs for a resident. Staff did not clean the catheter tubing or drainage spout, placed the graduate on the floor, and did not secure the catheter tubing with a leg strap. The CNA used incorrect techniques during peri care, including using the same area of a wash cloth for different skin areas and using paper towels. Interviews revealed staff were not following proper procedures.
Failure to Protect a Dementia Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA in the dining room during a meal. Security camera footage showed that after the resident, who was seated at a dining table, reached up and slapped the CNA on the arm, the CNA responded by striking the back of the resident’s right hand with an open hand. The video further showed the resident then reaching up toward the CNA, who grabbed the resident’s hand and forcibly shoved it down into the resident’s lap twice. The CNA then threw a bowl of food from the resident’s tray onto the table in front of the resident. The resident grimaced during the incident, and no physical injury was confirmed upon assessment. The resident involved had dementia and was documented as not cognitively intact on the Comprehensive MDS. The MDS also showed the resident was dependent on staff for activities of daily living, used a wheelchair for mobility, and had diagnoses including lack of coordination and generalized muscle weakness. The resident’s care plan identified potential for verbal and physical aggression, including hitting or swatting related to dementia, and directed staff to analyze triggers, anticipate needs, engage calmly in conversation, or walk away calmly if the resident became agitated. Despite these identified needs and planned interventions, the CNA’s response to the resident’s behavior was physically abusive. The facility’s abuse policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including staff-to-resident abuse, and required education for new and existing staff on prohibiting and preventing all forms of abuse. The CNA’s employee file showed that the CNA had not completed quizzes associated with multiple required Hand-In-Hand training modules on abuse prevention and dementia care. Staff interviews revealed that two aides heard slapping sounds in the dining room but did not witness the actual hitting, and one aide reported having previously heard the CNA state multiple times that the CNA would defend themself if necessary. Another aide later reported suspicion of abuse to the Administrator after overhearing dietary staff discuss the CNA’s comment about self-defense. Nursing staff stated they were not notified at the time of the incident and that they would have expected immediate reporting of any suspicion of abuse.
Failure to Notify Law Enforcement of Suspected Staff-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting policy by not immediately notifying law enforcement after an allegation and suspicion of staff-to-resident physical abuse. The facility’s policy, dated 2001, required that any suspected resident abuse be reported immediately to the administrator and to other officials according to state law, and that the administrator or the individual making the allegation immediately report the suspicion to law enforcement. A resident with dementia, lack of coordination, generalized muscle weakness, non-intact cognition, dependence on staff for ADLs, and wheelchair use was involved. Security camera footage from the dining room showed the resident seated at a table when a CNA delivered the meal tray; the resident reached up and slapped the CNA’s arm, and the CNA responded by hitting the resident’s hand, then twice grabbing and forcibly shoving the resident’s hand toward the resident’s lap, and throwing a bowl of food onto the table in front of the resident. A nurse aide on the opposite side of the dining room heard a slapping sound from the resident’s area and, upon turning, saw the CNA near the resident but did not witness the actual contact. The aide suspected the CNA had hit the resident but was unsure because the act was not seen. The following morning, after overhearing dietary staff say that the CNA had stated he/she would defend him/herself from residents if necessary, the aide reported the suspicion of physical abuse to the Administrator. The Administrator acknowledged not notifying law enforcement when the allegation was brought to her attention, explaining that another facility administrator had told her it was not necessary because the resident had no injury after being hit. The facility’s investigation confirmed via video that the resident slapped at the CNA, the CNA slapped the resident’s hand, forcefully subdued the resident’s hand twice, and that the resident grimaced, with no confirmed injury on assessment. Law enforcement was later contacted for presence at the facility related to the CNA’s termination, but not at the time the suspicion of abuse was first reported, contrary to facility policy.
Failure to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food storage areas to maintain sanitary conditions and proper food storage practices. Specifically, food debris was found under the three-compartment sink, and dirt and debris were present under the prep table. A metal storage rack above the prep table was covered in dirt and dust, and an uncovered cake was placed directly beneath this dirty rack. The refrigerator handles were sticky, a black substance was noted along the dish room floor drain, and a dust-covered fan was blowing across a tray with open glasses containing ice. Additionally, the trash can by the prep table lacked a lid, and a window near the prep table was dirty. In the dry storage area, a box of canned baked beans was stored directly on the floor. In the freezer, several opened packages of food items, including sausage patties, chicken patties, and French toast sticks, were undated and not properly sealed. Interviews with staff, including a dietary staff member, the Dietary Manager, the Registered Dietitian, and the Administrator, confirmed that food should be dated, stored in closed containers, and the kitchen should be kept clean and sanitary. Staff acknowledged that maintaining cleanliness is a shared responsibility, but sometimes tasks are overlooked. The facility's own policy requires the dining services manager to ensure cleaning and sanitation, with all staff trained on cleaning frequency and a posted cleaning schedule, but these standards were not met as evidenced by the observed unsanitary conditions and improper food storage.
Failure to Post and Follow Accurate Menus for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that posted menus were accurate, prepared in advance, and followed for residents, specifically affecting three residents with severe cognitive impairment and self-care deficits related to Alzheimer's disease or dementia. Observations revealed that the posted lunch menu listed breaded pork chop, au gratin potatoes, zucchini and tomatoes, cornbread, and frosted poke cake, but residents were instead served ham, cauliflower, and Jello with fruit. No alternate menu options were posted, and the menu board did not reflect what was actually served. Interviews with staff and a family member indicated that residents did not receive menus, were not asked about their meal preferences, and that staff were unclear about who was responsible for communicating with families regarding food choices. The Dietary Manager acknowledged that the wrong menu was posted and that the dietary department was responsible for updating menus daily, including posting alternates. The Activities Director stated that she did not ask residents in the memory care unit about their meal preferences, and believed kitchen staff were responsible for this task. These actions and inactions resulted in the facility not meeting its own policies for menu planning and resident participation.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident hit them in the head. The incident occurred in the dining room when one resident, who had a history of verbal and physical behaviors and was care planned for altercations, approached another resident and took their milk. After a brief interaction where the first resident awoke and bumped the other's arm, the second resident poured milk on the first and then struck them in the head before staff could intervene. The dietary staff separated the residents and notified nursing staff, who assessed both residents and found no injuries. The resident who was struck had multiple diagnoses, including palliative care, lung cancer, dementia, chronic kidney disease, COPD, cellulitis, major depressive disorder, and anemia. This resident was assessed as having moderately impaired cognition but was able to communicate and had not displayed behavioral issues. The resident who initiated the altercation had diagnoses of dementia, psychosis, anemia, pain, malnutrition, heart disease, and osteoarthritis, with severely impaired cognition and a history of behavioral issues, including altercations with other residents. Their care plan included interventions to monitor and separate them from others during meals. Despite the incident, the facility did not implement increased monitoring or closer supervision for the resident who initiated the abuse until six days later, when they were moved to a secured memory care unit. The facility's abuse policy required increased supervision and protective measures for residents involved in such incidents, but these were not put in place immediately following the event.
Failure to Maintain Infection Control Precautions During Wound Care
Penalty
Summary
Facility staff failed to maintain standard infection control precautions during wound care for two residents. Observations revealed that staff did not perform hand hygiene with glove changes, did not consistently wear personal protective gowns when required, and handled items such as glasses and treatment carts with contaminated gloves. In both cases, staff entered resident rooms and began wound care procedures without washing their hands, and did not change gloves or perform hand hygiene after touching their faces or other potentially contaminated surfaces. Additionally, staff did not always have the necessary PPE available near or outside the resident rooms, and signage indicating Enhanced Barrier Precautions (EBP) was absent. For one resident with multiple wounds and a history of heart failure, UTI, stroke, and anxiety, staff did not address wounds in the care plan or obtain a physician's order for EBP, despite the presence of wounds requiring such precautions. During wound care, staff failed to change gloves and perform hand hygiene at appropriate intervals, touched their faces and glasses with gloved hands, and handled treatment supplies with contaminated gloves. The resident's wounds were treated without adherence to EBP protocols, and staff interviews confirmed a lack of knowledge and training regarding EBP. For another resident with a stage 4 pressure ulcer and multiple stage 2 ulcers, staff similarly did not obtain a physician's order for EBP or include EBP in the care plan. During wound care, staff did not wear protective gowns as required, failed to perform hand hygiene before and after glove changes, and handled personal items and treatment supplies with contaminated gloves. Both staff members left the resident's room without performing hand hygiene. The Director of Nursing confirmed that these actions were not in line with facility expectations or policies.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple observations and interviews. Staff members, including the Dietary Manager and Dietary Aide B, were observed using improper handwashing techniques, such as using the same paper towel to turn off the faucet and dry their hands. This practice was acknowledged as unsanitary by both the staff and the facility's administration. Additionally, the facility's policy on handwashing and glove use was not consistently followed, contributing to the deficiency. The facility also failed to properly monitor and record food temperatures, which is crucial for preventing foodborne illnesses. Observations revealed that not all food items were temperature checked before being served to residents, and the food temperature logs were incomplete. For instance, hamburger patties and tomato soup were served without temperature checks, contrary to the facility's policy. Interviews with the Dietary Manager and staff confirmed that all foods should be temperature checked, but this was not consistently practiced. Furthermore, the facility did not maintain proper food storage and sanitation practices. Observations showed that food items were not dated when opened, and personal items were stored near food, which is against the facility's policy. Temperature logs for refrigerators and freezers were also incomplete, indicating a lack of regular monitoring. The facility's dishwashing practices were also deficient, as the dishwasher was not tested twice daily as required, and logs were not consistently completed. These lapses in food safety and sanitation practices contributed to the overall deficiency identified by the surveyors.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents in several instances. Staff members applied clothing protectors to residents in the dining rooms without asking for their consent, and they stood while assisting residents with eating, which is against the facility's policy. Additionally, a resident was left exposed to the hallway while wearing only a brief and T-shirt, with no privacy curtain pulled, despite being dependent on staff for personal hygiene and dressing due to severe cognitive impairment and cerebral palsy. The facility also failed to maintain privacy and dignity during medical procedures. Blood sugar levels were checked, and insulin was administered to residents in the dining room in the presence of other residents. This practice was observed with two residents, one of whom had a blood sugar level of 292 and received insulin in the dining room. The facility's policy requires such procedures to be conducted in private settings, such as the residents' rooms, to ensure dignity and privacy. Interviews with staff members, including CNAs and the Director of Nursing, revealed a lack of adherence to the facility's policies regarding resident dignity and privacy. Staff members acknowledged that they should sit while assisting residents with meals and should ask residents if they want clothing protectors. The Director of Nursing confirmed that staff are expected to pull privacy curtains when residents are exposed and to conduct medical procedures in private settings.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to promptly address and resolve grievances voiced by residents during resident council meetings, as evidenced by the lack of documentation and follow-up on issues raised. The facility's policy on resident rights and grievance handling, dated 1/1/24, mandates that residents should be supported in exercising their rights, including voicing grievances without fear of reprisal, and that the facility should respond to grievances. However, the review of resident council meeting notes from March, April, and May 2024 revealed that issues such as meal preferences, staff introductions, noise levels, cleanliness, and transportation were raised by residents but were not documented as resolved or followed up on. The notes also failed to indicate whether the resolutions were satisfactory to the residents or how they were informed about their rights or the process for reporting abuse and neglect. Interviews with residents and staff further highlighted the facility's shortcomings in addressing grievances. Residents reported that council meetings were irregular, lacked privacy, and did not include reviews of resident rights. They also expressed that they were not informed of any responses to their recommendations. The Activities Director, who facilitated the meetings, admitted to not having recent education sessions on grievance procedures and not receiving feedback from the administration on resident concerns. The Administrator acknowledged that residents should receive feedback on their grievances, indicating a gap between policy and practice in the facility's grievance handling process.
Lack of Access to Personal Funds After Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds after business hours and on weekends, which is a violation of resident rights. The facility's policy on resident rights, revised in December 2016, states that residents should be able to manage their personal funds or have the facility manage them. However, during a group interview, four residents reported that they did not have access to their funds during these times. The Business Office Manager confirmed that residents could only access their money when someone was in the office, and there was no access on weekends. The Administrator and Corporate Administrator acknowledged that residents currently do not have access to their funds after hours and that efforts are made to notify the business office in advance if funds are needed outside of business hours.
Deficiency in Managing Residents' Personal Funds
Penalty
Summary
The facility failed to properly manage and account for residents' personal funds, leading to negative balances in the facility's operating account for several discharged residents. The monthly petty cash reconciliation logs showed negative balances, indicating a lack of proper fund management. Specifically, four residents were affected, with negative balances ranging from -10.00 to -11,020.90 in the facility's operating account. The Business Office Manager, who was new to the position, was unaware of the reasons behind these negative balances and did not know the source of funds when the petty cash balance was negative. Additionally, the manager was uncertain about the timeframe for returning funds to residents or their guardians after discharge. Interviews with the Business Office Manager, an Accounting Firm Consultant, and the Regional Administrator revealed further issues. The Business Office Manager had not updated the Interim Aging report after issuing a check to a deceased resident, and there was confusion about whether funds had been refunded to a resident who moved to another facility. The Regional Administrator confirmed that there should be no negative accounting balances and that funds should be returned within 30 days of discharge. These deficiencies highlight a lack of proper financial management and oversight in handling residents' personal funds.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights periodically during their stay, both orally and in writing. The facility's policy on resident rights, revised in December 2016, outlined the rights of residents but did not specify when these rights should be communicated. During a group interview, four residents confirmed they had not received education about their rights. Additionally, a review of resident council meeting minutes from March to May 2024 showed no documentation that resident rights were reviewed. The Activity Director, who facilitated these meetings, admitted to not covering resident rights during the sessions.
Failure to Clarify Advance Directives
Penalty
Summary
The facility failed to clarify the status of advance directives for a resident, leading to a discrepancy in the resident's medical records. The resident, who was severely cognitively impaired and dependent on staff for daily activities, had conflicting orders regarding resuscitation status. The care plan indicated the resident was a Do Not Resuscitate (DNR), while the physician order sheet had conflicting entries, one indicating a DNR status and another indicating a full code status. The facility's policy requires that advance directives be prominently displayed in the medical record and that any changes be communicated to the care team. However, the inconsistency in the resident's resuscitation status was not addressed until the survey, indicating a lapse in following the established procedures for managing advance directives. This oversight could potentially lead to confusion among staff regarding the resident's treatment preferences.
Incorrect Use of Medicare Forms in Facility
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) to residents, which are essential for informing them about potential financial responsibilities for services not covered by Medicare. Specifically, the facility used incorrect forms for three out of twelve sampled residents. Resident #27 and Resident #28 were both given an outdated ABN form CMS-R-131 instead of the required SNF ABN form CMS-10055. Additionally, Resident #83 was provided with a Notice of Medicare Non-Coverage form that lacked a CMS number and an incorrect SNF ABN form. The facility's policy mandates the use of the current CMS-approved forms to ensure residents are properly informed about their Medicare coverage and potential liabilities. The Business Office Manager (BOM) is responsible for issuing these notices and maintaining a log of them. However, the review revealed that the facility did not adhere to these policies, resulting in the use of expired and incorrect forms. During an interview, the Administrator acknowledged the mistake of not using the correct forms.
Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, affecting all 29 residents. Observations revealed several deficiencies, including uncomfortable temperatures, with the south dining room recorded at 67 degrees, prompting residents to wear blankets and coats. The facility also had issues with cleanliness, as cobwebs were found in the chapel room, dust caked on bathroom fan coils, and strong odors of feces in certain hallways. Additionally, the facility struggled with maintaining its infrastructure, with chipped and broken tiles, missing blinds, and unsanded and unpainted drywall patches. Interviews with staff highlighted systemic issues contributing to these deficiencies. The Housekeeping Supervisor and Aides reported difficulties in obtaining hand sanitizer refills that fit the dispensers, and the Maintenance Supervisor acknowledged responsibility for cleaning fans and vents but noted a lack of replacement blinds and infrequent cleaning of wall heating units. The Administrator expressed expectations for a clean and homelike environment, including the replacement of broken tiles and blinds, repainting of missing paint spots, and ensuring the facility was free of odors. Resident council minutes further corroborated the ongoing issues, with residents repeatedly raising concerns about dust, unclean windows, and odors in various areas of the facility. Despite these complaints, resolutions were not documented in subsequent council minutes, indicating a lack of effective response to resident feedback. The combination of these factors contributed to the facility's failure to uphold a safe and comfortable environment for its residents.
Deficiency in Grievance Process Accessibility
Penalty
Summary
The facility failed to ensure that residents were aware of their right to file grievances, both in writing and anonymously, and did not provide the necessary contact information for the grievance official. The facility's policy outlined that grievances could be voiced verbally or in writing to staff members or grievance officials, and that information on how to file a grievance should be available to residents. However, during interviews, residents expressed that they were unaware of how to complete a grievance, did not have access to grievance forms, and did not know who the grievance officer was. Observations confirmed that grievance forms were not readily available to residents or their families. Interviews with staff revealed inconsistencies in the location and accessibility of grievance forms. An LPN mentioned that grievance forms were located in the employee break room, which residents could not access. The Administrator stated that forms were at the nurses' station but required residents or families to request them from staff. A CNA was unaware of the current grievance officer and how residents could submit anonymous grievances. Another CNA confirmed that forms were at the nurses' station but required staff assistance to access. The Administrator acknowledged that forms were not posted or accessible to residents or their families, and there was no means for anonymous reporting.
Failure to Implement Abuse and Neglect Policy
Penalty
Summary
The facility staff failed to implement their Abuse and Neglect policy by not completing necessary background checks and screenings for employees before they began working with residents. This deficiency affected eight out of ten sampled staff members, including LPNs, CNAs, housekeeping aides, and dietary aides. The facility's policy required background, reference, and credential checks to be completed on potential employees, but these were not conducted in a timely manner. For instance, the Family Care Registry checks for several employees were completed after their hire dates, and the Employee Disqualification List (EDL) and Certified Nurse Aide Registry were not checked for some staff. Interviews with the Business Office Manager and Corporate Administrator revealed that the background checks were not completed as required before staff started working. The Business Office Manager, who started in March, did not have access to run EDL checks or complete Family Care Registry checks. The Corporate Administrator confirmed that background checks should be completed upon hire and before staff begin working at the facility. This lack of adherence to the facility's policy on abuse and neglect prevention led to the deficiency noted in the report.
Failure to Conduct Comprehensive Assessments for Resident Preferences
Penalty
Summary
The facility failed to ensure accurate comprehensive assessments were completed on the Minimum Data Set (MDS) for two residents. For Resident #3, the MDS did not include preferences for customary routine and activities, and there was no evidence that interviews were conducted with the resident, family, or staff to determine these preferences. The resident had severe cognitive impairment and was involved in very few activities, despite having a care plan that included various interventions such as one-on-one visits and participation in activities like aromatherapy and listening to music. The daily activity sheets showed minimal engagement, with the resident participating in only three activities over a period of several months. Similarly, Resident #14's MDS lacked information on preferences for routine and activities, and no interviews were conducted with family or staff to gather this information. The resident had severe cognitive impairment and a history of anxiety, depression, and disinterest in activities. The care plan indicated that the resident would participate in activities of choice at least once a week, but there was no documentation to support consistent engagement in activities. The care plan also included interventions such as one-on-one visits and assisting the resident to the activity room, but these were not effectively implemented. The facility did not provide a policy on comprehensive assessments, and the Activity Director, who had been in the role since 2017 without any certifications, acknowledged the lack of care meetings since administrative changes. The Administrator expected interviews with family, significant others, or staff during comprehensive assessments, but this was not carried out. The absence of an MDS Coordinator further contributed to the deficiency in conducting thorough and accurate assessments.
Failure to Complete PASARR Screenings Prior to Admission
Penalty
Summary
The facility failed to ensure that staff completed a Level 1 PASARR screening for mental disorders or intellectual disabilities prior to admission for two residents. The facility's policy requires coordination with the PASARR program to screen all applicants for serious mental disorders or intellectual disabilities in accordance with Medicaid rules. A Level 1 screening should be completed before admission, and if positive, a Level II evaluation is required. However, for Resident #26, the Level 1 screening was not signed and did not indicate the required level of care, despite the resident having a diagnosis of unspecified psychosis and being on antipsychotic medication. Resident #14's records showed severely impaired cognition and dependence on staff for various activities of daily living. The resident was on multiple psychotropic medications and had diagnoses including dementia, anxiety disorder, and schizophrenia. Despite these conditions, there was no Level 1 PASARR located in the resident's medical record. The resident had been admitted from another long-term care facility, and a Level 1 PASARR was completed by the previous facility, but it did not trigger a Level II evaluation. Interviews with facility staff revealed that the responsibility for completing PASARRs lay with the Social Services department, which was currently understaffed, with the Administrator temporarily filling in. The facility's failure to complete the necessary PASARR screenings prior to admission for these residents represents a deficiency in adhering to regulatory requirements for pre-admission screening and resident review.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. For Resident #81, the care plan did not include the use of oxygen, despite a physician's order for oxygen therapy to maintain adequate oxygen saturation levels. This oversight was noted during an observation and confirmed through interviews with the Director of Nursing and a Licensed Practical Nurse, who acknowledged that care plans should address the use of oxygen. Resident #25's care plan was found lacking as it did not include an advance directive, even though the resident was documented as a full code in the physician's orders and electronic medical record. This gap in the care plan was highlighted during an interview with a Certified Nurse Aide, who indicated that code status information was typically accessed through stickers on doors or electronic records. For Resident #29, the care plan did not address the use of side rails or assist bars, despite the presence of a u-shaped rail on the resident's bed. The resident's admission MDS indicated severe cognitive impairment and a need for assistance with personal care, yet the care plan did not reflect these needs. Interviews with staff revealed that care plan meetings had not been conducted since administrative changes, and the facility lacked a social services or MDS coordinator, contributing to the deficiencies in care planning.
Deficiencies in Professional Standards and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of care in several instances, impacting multiple residents. For Resident #16, the staff did not obtain a physician's order for the use of a low air loss mattress, nor did they set the mattress according to the resident's weight, which was significantly lower than the setting used. Interviews with staff revealed a lack of clarity regarding who was responsible for adjusting the mattress settings, and the Director of Nursing confirmed that the settings were incorrect and should have been documented in the treatment administration record. For Residents #12 and #24, the facility did not secure physician's orders for blood sugar monitoring, despite both residents being prescribed insulin for diabetes management. Interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that there should have been orders specifying the frequency of blood sugar checks. This oversight indicates a failure to follow the facility's policy for medication and treatment orders, which requires such orders to be documented and consistent with safe and effective practices. Additionally, Resident #29 had a side rail on their bed without a physician's order, contrary to facility policy. Interviews with CNAs and the Director of Nursing revealed that the side rail was present because it was already attached to the bed, not due to a clinical need. Furthermore, documentation for Resident #24 was incomplete, with several entries missing in the Medication Administration Record and Treatment Administration Record, which the Director of Nursing and Administrator acknowledged as indicating that treatments or medications were not administered.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene care. Resident #24, who had severe cognitive impairment and was dependent on staff for personal hygiene, was not shaved as per his/her preference, despite expressing a desire to be shaved daily. Observations confirmed that the resident had noticeable hair growth, indicating a lack of grooming care. Interviews with staff revealed that shaving was only offered on shower days or upon resident request, which was not consistently adhered to. Resident #12, who had a left above-knee amputation and required extensive assistance with personal hygiene, did not receive oral care or have his/her face and hands washed during morning care. Despite being dependent on staff for these tasks, the care provided was incomplete, as confirmed by observations and staff interviews. The staff acknowledged the oversight and stated that oral care and washing should have been offered as part of the morning routine. Resident #16, who was severely cognitively impaired and dependent on staff for all ADLs, did not receive proper perineal care. During incontinent care, staff used the same area of a washcloth to clean different areas of the skin, which is against the facility's policy. This improper technique was observed during care and confirmed by staff interviews. Additionally, oral care was not provided to the resident, despite being dependent on staff for such care. The Director of Nursing confirmed that the expected standard of care was not met in these instances.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of several residents. Observations, interviews, and record reviews revealed that five out of twelve sampled residents were not engaged in activities that catered to their needs and preferences. The facility's policy outlined a comprehensive approach to activities, but the implementation was lacking, as evidenced by the minimal engagement of residents in activities over a period of several months. Resident #3, who was severely impaired and dependent on a wheelchair, was engaged in activities on only three out of 147 days. The care plan indicated daily one-on-one interactions and participation in activities like aromatherapy and listening to music, but these were not consistently documented or observed. Similarly, Resident #14, with severely impaired cognition and wandering behavior, was engaged in activities on only five days. Despite a care plan that included one-on-one visits and participation in activities like coloring and music, the resident was often observed pacing or sitting without engagement. Other residents, such as Resident #22, #24, and #25, also showed minimal participation in activities, with records indicating engagement on only a few days out of many. Interviews with staff, including the Activity Director, revealed a lack of resources, training, and support for conducting activities, particularly for residents with dementia. The Activity Director had no formal training or certification and faced budget constraints, which further hindered the ability to provide meaningful activities. Additionally, there was no dementia-specific training for staff, and activities were not planned for weekends or holidays, contributing to the deficiency in meeting residents' needs.
Failure to Lock Wheelchair Brakes During Transfers
Penalty
Summary
The facility failed to ensure proper safety measures during resident transfers, specifically by not locking wheelchair brakes, which is a critical step in preventing accidents. This deficiency was observed in the cases of three residents who were dependent on staff for mobility and required mechanical lifts for transfers. The facility's policy on using mechanical lifting devices did not explicitly state the need to lock wheelchair brakes during transfers, contributing to the oversight. Observations revealed that staff members, including CNAs, did not lock the wheelchair brakes while transferring residents using the Invacare hydraulic lift 9805P. Resident #16, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was transferred without the wheelchair brakes being locked. Similarly, Resident #24, with severe cognitive impairment and multiple diagnoses, was transferred from a wheelchair to a bed without the brakes being locked. Resident #3, who is dependent on a wheelchair and staff for mobility and personal care, was also transferred without the brakes being locked. Interviews with staff indicated a lack of training and awareness regarding the necessity of locking wheelchair brakes during transfers, as confirmed by the Director of Nursing.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide proper respiratory care for residents requiring oxygen therapy, as evidenced by several deficiencies observed during the survey. For one resident, the oxygen concentrator was set incorrectly at three liters instead of the prescribed two liters, and the humidified water bottle was found empty. Additionally, the oxygen tubing was on the floor and lacked a date, contrary to the facility's policy that requires tubing to be dated and changed weekly. This resident had severe cognitive impairment and was dependent on staff for various activities of daily living, with diagnoses including non-traumatic spinal cord dysfunction and cerebral palsy. Another resident, who had congestive heart failure, was observed with oxygen set at three liters, and the oxygen tubing was not dated. Interviews with staff revealed a lack of clarity regarding responsibilities for changing oxygen tubing and filling the humidified water bottle. Both CNAs and LPNs acknowledged that the oxygen tubing should not be on the floor and should be dated when changed, and that the humidified water bottle should contain sterile water. The facility's policy mandates these practices to ensure safe and appropriate respiratory care.
Failure to Assess and Manage Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for two residents, leading to potential safety risks. Resident #29 was not assessed for the risk of entrapment from bed rails before installation, and no physician's order was obtained for the use of side rails. Additionally, the facility did not measure entrapment zones for the installed side rails for this resident. The resident's care plan did not address the use of side rails or assist bars, and the monthly device schedule did not include the resident's room in zone measurements for side rail entrapment. Resident #14, who had severely impaired cognition and required substantial assistance with daily activities, was also not assessed for alternatives to side rails. Although a cane rail was ordered for bed mobility and repositioning, there was no side rail assessment completed, and the electronic medical record did not reflect any such assessment. The monthly device schedule showed inconsistent measurements of the bed rail zones over several months, indicating a lack of consistent monitoring and assessment. Interviews with facility staff revealed a lack of proper procedures and documentation regarding the installation and use of bed rails. Certified Nurse Aides and the Maintenance Supervisor indicated that side rails were installed without proper assessment or physician's orders, and the Administrator acknowledged that side rail assessments and measurements should be completed prior to installation. This lack of adherence to facility policy and regulatory requirements contributed to the deficiencies identified in the report.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure compliance with the requirement to have a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days a week. This deficiency was identified through interviews and a review of staffing records. The facility's policy, reviewed on January 1, 2024, stated the intent to comply with RN staffing requirements, yet staffing sheets revealed multiple instances where no RN was scheduled for the required hours. Specifically, there was no RN coverage for eight consecutive hours on several dates in October 2023, March 2024, April 2024, and May 2024. During an interview on May 30, 2024, the Administrator and the Director of Nursing acknowledged the requirement for RN coverage and the lapses in meeting this requirement.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 32% based on eight errors out of 25 opportunities. This affected four residents, including one who received crushed Senna and Thera-tabs M tablets through a PEG tube, contrary to guidelines that these medications should not be crushed. Additionally, the administration of Fluticasone Propionate nasal spray was incorrect, as the LPN did not follow the prescribed method, including failing to close one nostril and administering only one spray instead of two. Another resident did not receive Seroquel Rub as prescribed from March until late May due to a lack of supply, resulting in 64 missed doses. The medication was intended to be applied topically four times daily for unspecified psychosis. The staff was unaware of the duration the resident had been without the medication, indicating a lapse in medication management and communication within the facility. Furthermore, insulin administration errors were noted for two residents. The LPN failed to prime the insulin pens and did not clean the port with an alcohol wipe before attaching the needle, which is against the facility's policy. These errors in insulin administration were observed with both Novolog and Humalog insulin pens, highlighting a consistent issue with following proper procedures for insulin delivery.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in significant medication errors involving insulin administration for two residents. The facility's policy requires insulin pens to be primed before each use to prevent air from entering the insulin reservoir. However, observations revealed that an LPN did not follow this protocol. For one resident, the LPN removed the cap from a Novolog insulin pen, attached the needle without cleaning the port, and administered 14 units of insulin without priming the pen. Similarly, for another resident, the LPN administered Humalog insulin without priming the pen, following the same incorrect procedure. Interviews with the LPN and the Director of Nursing confirmed the failure to adhere to the facility's insulin administration policy. The LPN acknowledged the oversight in not cleaning the port and not priming the insulin pens before administration. The Director of Nursing reiterated that the staff should clean the insulin port with an alcohol wipe and prime the insulin pens with two units before administering insulin. These actions and inactions led to the deficiency in medication administration, affecting the residents' care.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as maintaining cleanliness in medication storage areas. During an observation, it was noted that a bottle of Flonase nasal spray belonging to a resident did not have a pharmacy label, and the resident's name handwritten on the bottle was mostly wiped off. Additionally, two medication drawers contained a sticky powdery substance, and the registered nurse on duty was unaware of who was responsible for cleaning the medication carts. Furthermore, medications were found left at the bedside of two residents, which is against the facility's policy. One resident, with severe cognitive impairment and multiple dependencies, had a medication cup with a clear liquid and crushed medication left on their bedside table. Another resident, also with severe cognitive impairment and various dependencies, had antifungal powder with miconazole nitrate 2% left on the sink in their room without a label, despite having no orders for such medication or for self-administration. Interviews with staff, including the LPN and DON, confirmed that medications should not be left at the bedside and should have proper pharmacy labeling.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to effectively manage the food and nutrition services. The job description for the DM position, dated 2020, required certification as a dietary manager, food service manager, or similar national certification, or an associate's or higher degree in food service management or hospitality. Additionally, two years of experience in food service management was required, with prior healthcare foodservice experience preferred. However, the DM, who had been in the position since April 2021, did not have the required dietary certification and was still enrolled in a 15-month program that would not be completed until November 2024. Interviews with the DM and facility administrators confirmed that the DM should have been certified, highlighting a gap in compliance with the facility's staffing requirements.
Infection Control Deficiencies in TB Screening and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of tuberculosis (TB) screening for newly hired employees. A review of employee files for six out of ten sampled staff members, including nurse aides and registered nurses, revealed that none had completed the required Mantoux test screening for TB prior to their hire dates. The facility's policy mandates that all healthcare workers be tested for TB upon hire and annually thereafter, with new employees not allowed to work until the test results are known. However, the Business Office Manager and Administrator acknowledged the oversight, indicating a lack of adherence to the policy. Additionally, the facility failed to provide alcohol-based hand rub (ABHR) on the memory care unit, as observed during multiple inspections. Hand sanitizer dispensers in various rooms and the North dining room were found empty, and staff interviews confirmed the absence of hand sanitizer on the unit since March. The facility's hand hygiene policy requires proper hand hygiene procedures to prevent infection spread, with ABHR being the preferred method in most clinical situations. Despite this, the facility experienced issues with receiving the correct hand sanitizer refills for their dispensers, leading to a prolonged period without adequate hand hygiene resources. Interviews with staff, including CNAs and the Housekeeping Supervisor, highlighted the ongoing challenges in maintaining hand sanitizer availability. The facility's supplier had discontinued the refills that fit the existing dispensers, resulting in a mismatch between the dispensers and the refills received. This issue persisted despite attempts to install new dispensers and redistribute existing ones from closed areas. The Director of Nursing was unaware of the hand sanitizer shortage, indicating a communication gap within the facility's management regarding infection control resources.
Inaccessible Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light system was accessible for residents in their rooms, leading to deficiencies in care. Observations revealed that call lights were out of reach for several residents, including those with severe cognitive impairments and dependencies on staff for personal care. For instance, one resident's call light was found on the floor, while another's was draped over a light fixture, making it inaccessible. These issues were observed across multiple rooms, affecting residents who required substantial assistance due to conditions such as dementia, anxiety disorders, and physical impairments. The facility's policy mandates that call lights be within reach of residents to allow them to call for assistance. However, the report highlights that in several instances, call lights were either not attached to the wall units or were placed in positions that residents could not access. This was particularly concerning for residents with severe cognitive impairments and those who were dependent on staff for mobility and personal hygiene. Interviews with staff confirmed that some residents did not understand the concept of using call lights, and there were instances where call light strings were missing or broken. The deficiency was further compounded by the facility's failure to address these issues promptly. Although maintenance staff had recently checked and installed call lights, there were still rooms without functioning call light strings. Staff interviews indicated a lack of consistent practice in ensuring call lights were within reach, with some staff acknowledging that call lights should not be draped over furniture or left on the floor. The facility's administrator also confirmed that call lights should be accessible to residents at all times.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for one of the residents, identified as Resident #30, at the time of their planned discharge. The facility's policy, revised in December 2016, mandates that a discharge summary and post-discharge plan be developed to assist residents in adjusting to their new living environment. This summary should include a comprehensive recapitulation of the resident's stay, their medical history, current diagnoses, functional status, and medication therapy, among other details. However, upon review, it was found that Resident #30, who was admitted on May 8, 2023, and discharged on April 3, 2024, did not have a discharge summary in their medical record. Resident #30's quarterly Minimum Data Set (MDS) indicated that they had intact cognitive skills and were independent in several activities of daily living, such as eating and toilet use, but required assistance with oral hygiene and personal hygiene. The resident had diagnoses including seizure disorder, anxiety, depression, high blood pressure, and PTSD. Despite these details, the facility did not provide a care plan for the resident, and the absence of a discharge summary was confirmed during an interview with the Administrator, who acknowledged that there should have been a recapitulation of the resident's stay in their medical record.
Unqualified Activity Director Employed
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program. The current Activity Director, who has been in the position since 2017, has not completed an approved activity professional training program. The director received only one day of training before assuming the role and has attended some general training sessions with other staff but lacks specific certifications in activity programming and dementia care. Interviews with the Corporate Administrator and the Administrator revealed a lack of awareness regarding the certification requirements for the Activity Director role. Additionally, the facility did not provide a policy outlining the training and requirements for activity professionals.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with severe cognitive impairment and a stage 3 pressure ulcer on the left heel. The resident, who was dependent on a wheelchair and always incontinent, was at risk for pressure ulcers and had unhealed pressure ulcers. Despite having physician orders to float the resident's heels in bed using pressure off-loading boots and to conduct weekly skin assessments, these orders were not consistently followed. Observations showed that the resident did not have the pressure-reducing boots on while in bed on multiple occasions, and there were missing entries for the required skin assessments and wound dressing checks. Interviews with facility staff, including an LPN and a CNA, revealed that there were issues with staff compliance in applying the resident's heel protectors as ordered. The Director of Nursing confirmed the expectation that the resident's orders for offloading heels should be followed. The facility also lacked a specific policy on pressure ulcers, which may have contributed to the inconsistency in care. The failure to adhere to the prescribed treatment and assessment protocols led to a deficiency in the care provided to the resident.
Improper Catheter Care and Peri Care Practices
Penalty
Summary
The facility failed to provide proper catheter care to prevent urinary tract infections for a resident. The staff did not clean the catheter tubing or the drainage spout and placed the graduate directly on the floor, which is against the facility's policy. The resident, who was always continent of urine and incontinent of bowel, did not have a leg strap to secure the catheter tubing, and the care plan did not address the use of a urinary catheter. During an observation, a CNA placed the graduate on the floor, emptied the drainage bag without cleaning the spout, and did not secure the catheter tubing with a leg strap. The CNA also failed to clean the urinary catheter tubing and did not separate and clean all skin folds during peri care. The CNA used a wash cloth incorrectly by using the same area to clean different parts of the skin and used a paper towel for peri care, which is not appropriate. Interviews with the CNA, another NA, and the DON revealed that the staff were not following proper procedures for catheter care and peri care. The CNA admitted to not using alcohol pads to clean the spout and not securing the catheter tubing. The DON confirmed that staff should not use the same area of a wash cloth for different areas of the skin, should not use paper towels for peri care, and should ensure the catheter tubing is anchored and cleaned.
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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