Magnolia Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 3421 Gasconade, Saint Louis, Missouri 63118
- CMS Provider Number
- 265672
- Inspections on file
- 29
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Magnolia Wellness Center during CMS and state inspections, most recent first.
A resident with a history of opioid dependence and behavioral issues repeatedly violated facility policies by bringing in contraband, hosting unauthorized guests, and leaving the facility without proper notification. Staff reported being unable to effectively intervene due to the resident's aggressive behavior and lack of clear guidance from administration. The care plan lacked specific interventions for these behaviors, and documentation of incidents and follow-up actions was inconsistent, resulting in a failure to provide necessary behavioral health care and services.
The facility did not consistently ensure that two nurses verified and signed the controlled substance inventory tracker sheets at shift changes, resulting in incomplete and inaccurate documentation for one floor. Despite policies requiring dual signatures and thorough recordkeeping, multiple instances were found where only one nurse signed or signatures were missing entirely, and some medication additions lacked proper documentation. This failure prevented accurate reconciliation of controlled substances as required by regulations.
A resident with severe cognitive impairment and total dependence for transfers was being moved using a Hoyer lift by two CNAs, who used an incorrect pad instead of the required large Hoyer sling. The straps broke during the transfer, causing the resident to fall and sustain a head laceration that required hospital treatment. Investigation confirmed that the wrong type of pad was used, and staff did not follow the care plan or facility policy.
Two separate incidents occurred in which a staff member verbally threatened and used profanity towards a resident, requiring intervention by other staff, and in another case, two residents were involved in a physical altercation after one, under the influence of alcohol, pushed and attempted to strike their roommate. Both incidents were witnessed by staff, confirmed through interviews, and resulted in a failure to protect residents from abuse and neglect as required by facility policy.
A dietary aide failed to provide requested condiments to a resident during meal service and engaged in an argument, including taunting and making derogatory remarks about the resident's appearance. Multiple staff witnessed the aide's unprofessional and disrespectful behavior, which violated the resident's right to dignity and respectful treatment.
A medication error rate exceeding 25% was observed when a single CMT was responsible for administering medications to about 40 residents, resulting in significant delays. Multiple residents reported receiving their medications late, and staff interviews revealed confusion about medication pass schedules. The facility failed to ensure medications were administered within the required time frame, leading to numerous errors and resident complaints.
The facility did not ensure Enhanced Barrier Precautions were implemented for residents with indwelling devices or wounds, as required. Staff provided care to multiple residents with feeding tubes and pressure ulcers without using gowns or posting EBP signage, and PPE supplies were not readily accessible. Interviews revealed staff were not adequately trained or informed about EBP requirements, and leadership confirmed that signage and supplies had not been put in place despite having them available.
Staff did not consistently notify physicians when two residents' blood glucose levels exceeded ordered parameters, as required by facility policy. Despite multiple high readings in residents with diabetes, there was no documentation of physician notification or follow-up in the medical records. Interviews with LPNs and the DON confirmed that staff are expected to report and document such events, but this was not done in these cases.
A resident with diabetes and cognitive impairment developed blisters on both feet that were documented by CNAs and co-signed by the ADON, but staff failed to notify the physician or initiate wound monitoring as required. The care plan did not address the actual wounds, and there were lapses in documentation and treatment administration, including missing initials on the TAR and undated dressings. The resident was also observed without prescribed pressure-relieving boots, and interviews revealed a lack of communication and follow-through among nursing staff regarding wound care protocols.
Two residents with significant cognitive and physical impairments did not receive recommended restorative nursing services after discharge from skilled therapy, as required by facility policy. Care plans lacked restorative interventions, physician notification was not documented, and staff interviews revealed the restorative program was inactive due to staffing and communication issues.
Two residents were involved in a physical altercation after one, who was already agitated and verbally aggressive, was allowed to go outside unsupervised with another resident. Despite staff awareness of the agitation and existing care plans for behavioral issues, preventive interventions were not implemented, resulting in one resident being choked and sustaining visible bruising and a sore throat before staff intervened.
Staff failed to intervene appropriately during episodes of resident agitation and aggression, resulting in one resident kicking another and a separate incident where a resident was choked by a peer, causing visible bruising and a sore throat. Despite care plans outlining the need for early intervention and de-escalation, staff did not consistently implement these strategies, and some were unaware of the required interventions, leading to preventable resident-to-resident altercations.
A resident with severe cognitive impairment and a history of wandering and aggression placed their hands around another resident's neck in a hallway altercation. Staff intervened immediately, but the incident highlights a lapse in monitoring and intervention, as the aggressive resident's care plan included measures to prevent such behavior.
The facility failed to monitor and intervene for a resident in respiratory distress, leading to delayed treatment and the resident's subsequent death. The resident was found unresponsive and not connected to a working oxygen source. EMS found the resident in critical condition, and the facility's policies did not adequately address emergency situations.
Failure to Provide Necessary Behavioral Health Services and Address Repeated Policy Violations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for multiple residents, specifically by not addressing ongoing behavioral issues such as repeated violations of drug and alcohol, out on pass, visiting, and contraband policies, as well as physical and verbal aggression toward other residents and staff. One resident with a history of opioid dependence and other psychoactive substance abuse was frequently observed leaving and returning to the facility at all hours, often without signing in or out, and sometimes refusing or missing prescribed medication doses. The resident also repeatedly brought unauthorized guests into the facility, including overnight stays, and was found with contraband items such as box cutters, utility blades, and lighters in their room. Staff interviews revealed that the resident would become hostile or threatening when confronted about these behaviors, leading staff to avoid entering the resident's room or addressing the issues directly. Despite the facility's policies requiring timely assessment, documentation, and intervention for adverse behavioral symptoms, there was a lack of consistent documentation and follow-up regarding the resident's behaviors and the presence of contraband. The care plan did not include interventions for the resident's repeated policy violations, such as bringing guests into the facility at inappropriate times, leaving the facility without proper notification, or bringing in potentially dangerous items. Staff reported uncertainty about their roles in monitoring for contraband and managing the resident's behaviors, with some believing that only housekeeping should check rooms, and others stating they were told not to confront the resident due to his aggressive demeanor. Interviews with staff, including LPNs, CNAs, and the Social Worker, indicated that administration was aware of the ongoing issues but did not provide clear guidance or effective interventions to address the resident's non-compliance and behavioral health needs. The Social Worker noted that the resident was not on a behavior contract and was often not present when psychiatric services were available. The DON and Administrator had removed contraband items from the resident's room on several occasions, but the resident continued to bring in more. Staff expressed concerns for their safety and the safety of other residents, as there were no clear instructions on how to manage the resident's aggressive or non-compliant behavior, especially when administration was not present.
Failure to Maintain Accurate Controlled Substance Inventory Records
Penalty
Summary
The facility failed to maintain accurate and thorough records of receipt and disposition of controlled substances, as required by both federal and state regulations. Review of the facility's policies indicated that controlled substances must be documented with the date, time, and signatures of the receiving personnel, and that shift change inventory counts must be verified and signed by two nurses. However, examination of the controlled substance inventory sheets for one of the two facility floors revealed multiple instances where only one nurse signature was present, or where there was no documentation of signatures at all for both morning and evening shift changes. There were also occasions where the total number of medication cards was inconsistent or not documented, and instances where medications were added without corresponding documentation of the resident or medication details. Interviews with staff confirmed that the expected practice was for two nurses to count and sign off on the narcotic inventory tracker at each shift change and whenever the narcotic box was accessed. One LPN stated that he/she always counted narcotics with another nurse and suggested that missing signatures were likely due to the other staff member forgetting to sign. The DON and Administrator both confirmed their expectation that two staff members sign off on every entry, both at shift changes and when the narcotic box was accessed for any reason. Despite these expectations, the documented records showed repeated failures to comply with the facility's own policy and regulatory requirements for controlled substance accountability. The lack of consistent dual signatures and incomplete documentation prevented accurate reconciliation of controlled substances, as required to ensure proper pharmaceutical services for residents. No specific residents were identified as being directly affected in the report, and the census at the time was 80.
Resident Fall Due to Incorrect Sling Use During Hoyer Lift Transfer
Penalty
Summary
Staff failed to provide adequate assistance to prevent accidents when two CNAs used a Hoyer lift to transfer a resident but did not use the correct size or type of sling. During the transfer, the sling straps broke while the resident was suspended in mid-air, resulting in the resident falling to the ground and sustaining a laceration to the back of the head. The resident required hospital evaluation and sutures for the injury. The resident involved had severe cognitive impairment, was dependent on staff for all transfers, and had diagnoses including stroke with right-sided hemiplegia, seizures, non-Alzheimer's dementia, and malnutrition. The care plan specified the need for two staff members to assist with Hoyer lift transfers and the use of a large sling, as ordered by the physician. Despite these requirements, staff used a pad that was not the correct Hoyer sling, and it was later determined that a slide transfer pad, which resembled a Hoyer pad but was not designed for use with the lift, was used instead. This led to the failure of the straps and the resident's fall. Interviews and record reviews revealed inconsistencies in staff accounts regarding who was present during the incident, but it was confirmed that the wrong pad was used and that the staff did not follow the resident's care plan or the facility's policy for mechanical lift transfers. The incident occurred at the end of a shift, and the resident was found on the floor with a head laceration. The facility's investigation concluded that the use of the incorrect pad directly contributed to the accident.
Failure to Prevent Abuse and Neglect Among Residents and Staff
Penalty
Summary
The facility failed to protect residents from abuse and neglect in two separate incidents. In the first incident, a staff member engaged in a verbal altercation with a resident, during which both parties exchanged insults and profanity. The staff member escalated the situation by making a threatening statement towards the resident and using inappropriate language, including insults about the resident's mother. Multiple staff and resident interviews confirmed that the staff member had to be physically held back by other staff to prevent further escalation. The resident involved was cognitively intact and had a history of verbal aggression, but at the time of the incident, there was no physical contact or injury reported. In the second incident, two residents were involved in a physical altercation. One resident, who had a diagnosis of alcohol abuse and was under the influence at the time, became angry with their roommate for making noise early in the morning. The aggressive resident pushed the other resident to the floor and attempted to strike them, but missed. Staff intervened and separated the residents. The resident who was pushed had severe cognitive impairment but did not sustain any injuries and reported feeling safe after the incident. The aggressive resident admitted to consuming alcohol and had previously signed a behavior agreement to refrain from alcohol use and aggressive behavior. Both incidents were witnessed by staff and corroborated through interviews and documentation. The facility's policies required staff to prevent, identify, and report abuse, but in these cases, the staff member's actions and the resident-to-resident altercation were not prevented, resulting in violations of residents' rights to be free from abuse and neglect. The events were reported to the appropriate facility leadership and law enforcement, and the facility's failure to prevent these incidents constituted a deficiency.
Failure to Honor Resident Dignity and Respect During Meal Service
Penalty
Summary
A deficiency occurred when a dietary aide (DA) failed to accommodate a resident's request for condiments during meal service and engaged in an argument with the resident. The resident, who was cognitively intact and had diagnoses including depression and an unspecified mood disorder, requested salt and pepper during breakfast. The DA informed the resident that there were no condiments available and did not attempt to fulfill the request. The resident then went to another floor to obtain the condiments independently. Upon returning, the DA taunted and insulted the resident, making derogatory remarks about the resident's appearance and age. Multiple staff members witnessed the exchange, reporting that the DA laughed at the resident, called the resident names such as 'skinny' and 'bald-headed,' and used inappropriate language. The situation escalated as the DA continued to argue with the resident, despite being instructed by a nurse to stop. The argument included cursing and threats, with both the DA and the resident exchanging hostile words. The DA admitted to being irritated by the resident and acknowledged making inappropriate comments during the altercation. The facility's policies and job descriptions require staff to treat residents with dignity and respect, to provide prompt and polite service, and to deescalate situations when residents become agitated. In this incident, the DA did not follow these protocols, failed to meet the resident's needs, and engaged in unprofessional and disrespectful behavior, resulting in a violation of the resident's right to dignity and respectful treatment during meal service.
High Medication Error Rate Due to Delayed Administration and Policy Noncompliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. Out of 34 observed medication administration opportunities, nine errors were identified, resulting in a 26.47% error rate. These errors were primarily due to medications being administered outside the required time window, with several residents receiving their scheduled morning medications significantly later than ordered. Observations showed that a single Certified Medication Technician (CMT) was responsible for passing medications to approximately 40 residents on one hall, leading to delays. The CMT reported starting the medication pass at 7:30 A.M. and not finishing until after 11:00 A.M., with some residents receiving their 8:00 A.M. medications as late as 10:36 A.M. or later. Multiple residents, including those attending a Resident Council meeting, voiced concerns about consistently receiving medications late. Interviews with staff revealed confusion regarding whether the facility was operating under a traditional or liberalized medication pass schedule, with both the Director of Nursing and the Administrator unaware that specific times were still being used. The facility's policy required medications to be administered within one hour before or after the scheduled time, and administration outside this window was considered a medication error. The combination of insufficient staffing, lack of clarity on medication pass schedules, and failure to adhere to policy led directly to the high medication error rate and resident complaints.
Failure to Implement Enhanced Barrier Precautions and Ensure PPE Availability
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents at risk of multidrug-resistant organism (MDRO) transmission. Observations, interviews, and record reviews revealed that residents who required EBP did not have the required signage on their doors or walls instructing staff to use EBPs during personal care. Additionally, personal protective equipment (PPE) such as gowns, masks, and goggles/face shields were not readily accessible for staff use in the care of these residents, with only gloves being available in or near the rooms. Multiple residents with significant medical needs, including those with feeding tubes, pressure ulcers, and other indwelling devices, were identified as requiring EBP. For example, one resident had a gastrostomy tube and both Stage 3 and Stage 4 pressure ulcers, while another had a feeding tube and was at risk for pressure ulcers. Despite these conditions, there was no documentation in the care plans or medical records indicating that staff were using EBP during care. Direct observations showed that staff, including LPNs and CNAs, provided care to these residents using only gloves and not gowns, even when performing high-contact activities such as wound care and handling feeding tubes. Interviews with staff members revealed a lack of awareness and training regarding EBP requirements. Several CNAs and LPNs stated they were either unaware of which residents required EBP or did not know that gowns should be worn in addition to gloves. Some staff indicated they would have used gowns if they were available, but supplies were not accessible. Leadership acknowledged that EBP signs and supplies were not in place, citing delays in receiving containers for PPE, but confirmed that the necessary supplies were on hand. A list provided by the DON identified 18 residents who should have had EBP signage and supplies available, but these measures were not implemented at the time of the survey.
Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that staff consistently notified physicians when residents' blood glucose levels exceeded the parameters ordered by the physician. According to the facility's policy, staff are required to inform the physician of significant changes in a resident's condition, including when blood glucose levels fall outside of specified ranges, and to document these notifications. However, review of medical records and interviews revealed that this protocol was not followed for two residents with diabetes who had orders for routine blood glucose monitoring. One resident with a history of diabetes, hypertension, and dementia had multiple blood glucose readings above the ordered threshold of 250, including values of 301, 272, 274, 285, and 401. There was no documentation in the Medication Administration Record or progress notes that the physician was notified of these elevated readings. Similarly, another resident with diabetes, dementia, and malnutrition had a blood glucose reading of 540, which exceeded the physician's ordered parameter of 400, but there was no evidence that the physician was contacted or that this was documented in the resident's records. Interviews with nursing staff and the Director of Nursing confirmed that staff are expected to notify the physician and document any blood glucose readings outside of the ordered parameters, but in these cases, there was no documentation of such notifications. The lack of communication and documentation regarding these significant changes in residents' conditions constituted a failure to meet professional standards of quality for monitoring and reporting in diabetic care.
Failure to Notify Physician and Monitor Wounds Following Discovery of Foot Blisters
Penalty
Summary
Facility staff failed to ensure that a resident with diabetes, dementia, and malnutrition received appropriate wound care and physician notification after blisters were observed on both feet. Despite documentation of blisters on shower review forms by CNAs and co-signature by the ADON, there was no evidence that the physician was notified or that wound monitoring was initiated as required by facility policy. The ADON assumed the wound nurse was aware and did not document her assessment or communicate with the wound nurse, and the wound nurse confirmed she was not notified until much later. The resident's care plan included general interventions for diabetes, such as daily foot inspections, but did not address the actual wounds present on the feet. Multiple skin assessments and shower review forms documented the presence of blisters and open areas, but there were no corresponding physician orders or progress notes regarding these wounds for over two weeks. When wound care orders were finally obtained, there were lapses in documentation, including missing initials on the Treatment Administration Record (TAR) and undated dressings on the resident's feet. Observations revealed that the resident was not consistently wearing prescribed pressure-relieving boots, with the boots found on a second bed rather than on the resident. Interviews with nursing staff confirmed a lack of communication and follow-through regarding wound care protocols, including failure to notify the physician, incomplete documentation, and lack of coordination between staff members. These failures resulted in delayed treatment and incomplete monitoring of the resident's wounds.
Failure to Provide Restorative Nursing Services After Discharge from Skilled Therapy
Penalty
Summary
The facility failed to provide services and/or treatment to maintain or improve range of motion (ROM) for residents who required restorative nursing interventions after discharge from skilled therapy. Specifically, the facility did not maintain a measurable, goal-oriented restorative nursing or exercise program as outlined in its own policy. Of 11 residents discharged from skilled therapy, two were identified as not receiving the recommended restorative therapy. The facility's Restorative Nursing Program Guidelines require interdisciplinary team (IDT) review, physician notification, individualized care planning, and regular documentation, none of which were consistently followed for these residents. One resident with severe cognitive impairment, hemiparesis, and a history of stroke required partial to moderate assistance with activities of daily living (ADLs) and used a wheelchair for mobility. The occupational therapy (OT) discharge summary recommended a restorative program, including a dining/swallowing program and ROM exercises. However, there was no documentation that the physician was notified of these recommendations, and the resident's care plan did not include ROM or restorative therapy interventions. Forms related to ROM and eating lacked documentation of frequency, and the resident reported not receiving restorative therapy or knowing when they were last evaluated. Another resident with moderate cognitive impairment, anemia, congestive heart failure, and high blood pressure was also discharged from OT with recommendations for a restorative dining/swallowing program and adaptive equipment. The care plan did not reflect these OT recommendations or restorative therapy interventions, and the relevant forms were incomplete. Staff interviews revealed that the restorative aide had not performed restorative exercises for any residents due to other commitments, and there was confusion among staff regarding oversight and implementation of the restorative program. The program was not active, and communication between therapy, nursing, and administration was unclear, resulting in residents not receiving the restorative care recommended by therapy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when two residents were involved in a physical altercation that resulted in one resident being choked, causing visible bruising and a sore throat. Prior to the incident, the resident who was later choked had been agitated and verbally aggressive, with staff noting the resident was yelling at others about food issues. Despite this agitation, the resident was allowed to go outside to the patio, where the altercation with another resident occurred. Staff were present and aware of the resident's heightened agitation but did not intervene to prevent the two residents from being together in an unsupervised setting. The resident who committed the choking had a diagnosis of Alzheimer's Disease but was assessed as cognitively intact and had no prior history of physical behavioral symptoms directed toward others. The resident who was choked was also cognitively intact and had a history of depression and poor impulse control, with care plans in place addressing potential for physical and verbal aggression. Staff and social services were aware of the resident's agitation earlier in the day, and the care plan included interventions for de-escalation, but these were not effectively implemented prior to the altercation. Multiple staff interviews confirmed that the altercation escalated from a verbal argument to physical violence, with staff intervening only after the choking had begun. The facility's abuse prevention policy required proactive intervention and monitoring of residents with known behavioral issues, but staff actions were reactive rather than preventive. The failure to intervene before the situation escalated resulted in physical harm to a resident, in violation of the facility's abuse prevention and prohibition program.
Failure to Provide Necessary Behavioral Health Interventions Leads to Resident-to-Resident Altercations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services when staff did not intervene appropriately during incidents involving agitated and aggressive resident behavior. One resident, who was cognitively intact and had a history of depression and poor impulse control, became agitated and verbally aggressive, escalating to physically kicking another resident who was severely cognitively impaired and had a history of daily physical behavioral symptoms. Staff did not intervene before the situation escalated, despite care plan interventions that required early intervention and de-escalation strategies when the resident became agitated. Additionally, the same resident was involved in a verbal altercation with another cognitively intact resident, which escalated to physical aggression when the second resident wrapped their hands around the first resident's neck, resulting in visible bruising and a sore throat. Staff interviews and documentation revealed that while some attempts at verbal redirection and separation were made, staff were not consistently aware of or did not implement all required interventions outlined in the residents' care plans. Several staff members admitted to not knowing the specific interventions for the residents involved, and there was a lack of proactive measures to prevent escalation, as required by facility policy. The facility's behavior management policy emphasized the need for individualized, proactive interventions and ongoing assessment to prevent behaviors that could harm residents or others. However, the report documents that staff failed to intervene before agitation escalated in both incidents, and did not consistently monitor or implement care plan strategies designed to de-escalate situations and protect residents from harm. The lack of timely and effective intervention contributed to physical altercations between residents, resulting in injury and distress.
Resident-to-Resident Altercation Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from abuse when two residents were involved in a physical altercation. One resident, who had severe cognitive impairment and a history of wandering and aggressive behavior, placed their hands around another resident's neck. The incident occurred in the hallway outside the second resident's room, and staff intervened immediately to separate the residents. The resident who was attacked did not report any pain or injury, although there was redness on their neck, which they attributed to wiping drool off with a cloth. The resident who initiated the altercation had a care plan that identified them as having severe cognitive impairment, wandering behavior, and a history of physical aggression related to dementia. Despite these known issues, the resident was able to approach and physically engage with another resident, indicating a lapse in monitoring or intervention. The care plan included interventions such as administering medications, monitoring for signs of aggression, and redirecting the resident from wandering, but these measures were not sufficient to prevent the incident. The facility's investigation revealed that the incident was discovered immediately by staff, who heard screaming and found the resident with their hands on the other resident's neck. The staff acted quickly to separate the residents and assess the situation. However, the fact that the incident occurred suggests that the existing interventions and monitoring were inadequate to prevent the resident's aggressive behavior from escalating to physical contact with another resident.
Failure to Monitor and Intervene for Resident in Respiratory Distress
Penalty
Summary
The facility failed to provide acceptable nursing services by not directly and continuously monitoring and intervening for a resident who was in respiratory distress. Two therapy staff found the resident difficult to wake, breathing heavily, and not connected to the oxygen concentrator, which was broken. The emergency oxygen tank on the resident's wheelchair was also found empty, further delaying treatment. When staff finally applied the nasal cannula with oxygen at 4 liters from a full e-tank, the resident's oxygen saturation level was critically low at 68%. The resident had an order for a BiPap, which was not applied when the resident was noted to be in distress. When Emergency Medical Services (EMS) arrived, the resident was unattended, prone on a flat bed, with audible rales, thick white sputum, peripheral cyanosis, and an oxygen saturation level of 57%. EMS placed the resident on a nonrebreather mask at 15 liters, but the resident's condition continued to deteriorate. The resident was transferred to the hospital, where they expired a short time later. The facility's policies on abuse and neglect, pulse oximetry, oxygen administration, and acute condition changes did not adequately address emergency situations such as respiratory distress. Interviews with staff revealed that the resident was known to wear oxygen and did not refuse care. However, there was a lack of consistent monitoring and documentation of the resident's oxygen use and condition. Staff members reported the resident's change in condition to the nurse, but appropriate and timely interventions were not taken. The facility's failure to monitor and intervene promptly and effectively contributed to the resident's critical condition and subsequent death.
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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