Maple Grove Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fenton, Missouri.
- Location
- 560 Corisande Hill Rd, Fenton, Missouri 63026
- CMS Provider Number
- 265395
- Inspections on file
- 15
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Maple Grove Wellness & Rehabilitation during CMS and state inspections, most recent first.
A nurse failed to verify a resident's identity and administered another resident's morphine sulfate and lorazepam, resulting in the resident experiencing adverse symptoms and requiring Narcan and hospital transfer. The nurse did not follow the facility's medication administration policy, including the required identity checks and communication with the resident.
Nineteen residents did not receive prescribed medications or treatments when an LPN refused to cover a hallway after another nurse left early, and the DON was unable to secure agency coverage in time. Residents with conditions such as diabetes, hypothyroidism, and heart disease missed critical care, and staff attempts to notify the DON during the shift were unsuccessful.
Facility staff did not notify the physician of a resident's urine culture and sensitivity results, which showed E. coli resistant to the prescribed antibiotic Bactrim DS. The resident, with multiple chronic conditions, was treated for cellulitis, but the required communication of lab results to the physician did not occur, as the Infection Preventionist failed to follow protocol.
The facility failed to provide the required minimum of two showers per week for five residents, leading to complaints and observations of poor hygiene. Residents with various medical conditions requiring assistance for bathing reported infrequent showers and unkempt appearances. The facility's policy was not followed, and the administrator acknowledged the expectation for regular showers.
The facility failed to repair essential kitchen equipment and ensure proper food storage in residents' personal refrigerators. Observations revealed malfunctioning kitchen appliances and expired, improperly stored food items. Interviews indicated a lack of clear responsibility and process for maintaining the refrigerators, leading to potential health risks for residents.
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). Despite having policies outlining the QAPI process, the facility did not have a QAPI plan in place. The Administrator admitted they are starting fresh with QAPI and could not find any past documentation, with no Performance Improvement Projects (PIPs) in place.
The facility failed to ensure the QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. Key personnel did not attend the QAPI meeting, and no Performance Improvement Projects (PIPs) were in place. The Administrator admitted to starting fresh with QAPI and lacking past documentation, indicating a failure to address systemic quality deficiencies.
The facility failed to hold quarterly QAPI meetings with the required members, as mandated by their policy. A review showed no evidence of key members attending a recent meeting, and the Administrator admitted to not finding documentation of past meetings or having any PIPs in place. The facility census was 92 residents.
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92.
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, affecting all residents. Nursing schedules from February to April 2024 showed 11 days without RN coverage. The Administrator acknowledged the expectation for RN coverage, and the facility lacked an RN coverage policy.
The facility failed to notify residents of the availability and location of the most recent survey results. Multiple residents were unaware of a binder containing survey results, and the Administrator admitted the results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table.
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. Interviews with staff revealed confusion about the methods for determining code status, resulting in conflicting information being recorded.
The facility failed to provide a safe, clean, comfortable, and homelike environment. Observations revealed debris on a resident's oxygen concentrator, unpainted drywall patches, stained privacy curtains, and missing closet drawers. The Administrator and Director of Operations acknowledged these issues, indicating a deficiency in maintaining the expected standards.
The facility failed to provide adequate discharge documentation for a resident transferred to another facility, including a discharge summary and recapitulation of the resident's stay. Interviews with staff revealed a misunderstanding of the discharge policy, leading to the omission of required documentation.
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents. Despite the facility's policy requiring written notification, the Social Services Director admitted that this was not done, and the Administrator and Director of Operations expected staff to provide this information, highlighting a discrepancy between policy and practice.
The facility failed to complete significant change MDS assessments within the required 14-day timeframe for two residents following their discharge from hospice services. The Administrator, Director of Operations, and MDS Coordinator acknowledged the oversight, which did not comply with the RAI Manual requirements.
The facility failed to document accurate MDS assessments for five residents, leading to discrepancies in their medical records. Errors included incorrect indications of insulin use, inaccurate diagnoses, and omissions of several medical conditions. Interviews with staff confirmed these inaccuracies, highlighting a failure to adhere to the facility's MDS completion and submission guidelines.
The facility failed to update and revise care plans for two residents, omitting critical interventions such as PICC line management. This deficiency was acknowledged by the Administrator and Director of Operations, who stated that care plans should reflect the current condition of the residents.
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. One resident had inconsistent administration times for levothyroxine and was observed wearing prevalon boots without an order. Another resident also had inconsistent levothyroxine administration times, leading to abnormal TSH levels.
The facility failed to follow professional standards for PICC line care for two residents. One resident's PICC line dressing was not changed weekly, and the infusion was not disconnected or flushed promptly. Another resident's PICC line dressing was not changed weekly, and the line was accidentally pulled out during a dressing change, requiring replacement. The facility did not adhere to physician orders and professional standards for PICC line care.
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. Medical records showed lapses in compliance, with missing documentation for annual TB tests and screenings. The facility's census was 92, indicating potential broader non-compliance issues.
The facility failed to provide a dining room large enough to accommodate all residents, leading to overcrowding and discomfort. Observations showed insufficient seating, and residents reported having to take food back to their rooms or wait for a seat. The Director of Operations acknowledged the issue but did not provide a satisfactory solution.
The facility failed to maintain a safe environment by allowing items to be stored on overbed light fixtures in multiple rooms. Observations included stuffed animals and crafts placed on the lights, posing a potential fire hazard. The facility did not have a specific policy for overbed lighting safety, although the admission packet prohibited such practices.
The facility failed to provide at least twelve hours of annual in-service education for two CNAs, with one CNA receiving only one hour and another receiving four hours of training. The Administrator confirmed the expectation of twelve hours of training per year, and the facility lacked an in-service training policy.
The facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors. Observations showed the information was not visible near nurse's stations or the main lobby. A CNA confirmed it was posted in the nurse's office, making it inaccessible to residents or visitors. The Administrator expected the information to be posted in a prominent location.
Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's prescribed medications—morphine sulfate and lorazepam oral concentrate—to a cognitively intact resident with multiple chronic conditions, including diabetes, chronic kidney disease, heart failure, COPD, chronic respiratory failure, and chronic pancreatitis. The nurse failed to verify the resident's identity, did not explain the medications being administered, and did not confirm the resident's name prior to administration. The nurse was running behind on the medication pass and, in haste, called out the intended recipient's name, to which the wrong resident responded, and then administered the medications without further verification. Shortly after receiving the incorrect medications, the resident experienced nausea and a rapid decline in condition, including changes in vital signs and mentation. The resident reported that the nurse did not communicate or identify herself, nor did she provide any information about the medications being given. The error was discovered when the resident questioned what had been administered and another nurse intervened to monitor the resident's condition. The facility's medication administration policy required verification of resident identity and adherence to the seven rights of medication administration, including the right resident, right medication, and right dose. The nurse involved admitted to not following these protocols due to being in a hurry. The incident resulted in the resident requiring administration of Narcan and transfer to the hospital for further evaluation.
Failure to Administer Medications and Treatments Due to Staffing Refusal
Penalty
Summary
The facility failed to follow physician's orders for 19 residents on the 100 hall, resulting in missed administration of critical medications and treatments. The review of medical records and medication administration records revealed that residents with diagnoses such as Type II Diabetes Mellitus, Hypothyroidism, Coronary Heart Disease, pneumonia, COPD, and Muscular Dystrophy did not receive prescribed medications, including various types of insulin, Levothyroxine, antibiotics, pain medication, and inhalation treatments. Blood sugar checks and other ordered care were also not performed as required by the residents' care plans and physician orders. The deficiency occurred during the night shift when only one nurse, an LPN, remained after the scheduled nurse for the 200 hallway left early. The LPN assigned to the 100 hallway refused to provide care or administer medications to the residents on that hall, stating discomfort with covering both hallways due to limited experience at the facility. The Director of Nursing (DON) was informed of the staffing issue and attempted to secure an agency nurse, who was expected to arrive by 11:00 P.M., but did not arrive until the morning. The DON left the facility after giving the keys to the LPN, who refused to accept responsibility for the 100 hallway. Throughout the night, no medications or treatments were administered to any residents on the 100 hallway. Staff, including a CNA, attempted to contact the DON to report the ongoing issue, but did not receive a response until after the shift. The following morning, the LPN confirmed to the DON that no care had been provided to the 100 hallway residents, and subsequently resigned. The facility did not provide a policy on medication administration when requested.
Failure to Notify Physician of Antibiotic-Resistant UTI Lab Results
Penalty
Summary
Facility staff failed to ensure proper antibiotic stewardship for a resident when they did not notify the resident's physician of the results from a urine culture and sensitivity (C&S) test. The resident, who had a history of diabetes, chronic kidney disease stage 2, COPD, hypertension, and adult failure to thrive, complained of burning during urination and had a urine sample collected. The physician was contacted for other symptoms and prescribed Bactrim DS for cellulitis, but there was no documentation that the physician was informed of the urine C&S results, which later showed Escherichia coli resistant to Bactrim DS. The facility's policy required staff to communicate pertinent clinical information, including lab results, to physicians to promote appropriate diagnosis and antibiotic prescribing. However, the Infection Preventionist, who was responsible for reviewing lab results and notifying the physician, did not follow this protocol. The Director of Nursing confirmed that the physician was not made aware of the urine C&S results, and the physician stated that a different antibiotic would have been prescribed if notified. There was no documentation that the alternate physician reviewed the lab results during a subsequent visit.
Failure to Provide Adequate Showering for Residents
Penalty
Summary
The facility failed to provide a minimum of two showers per week for five out of six sampled residents, potentially affecting all residents in the facility with a census of 92. The facility's policy stated that residents should be offered a shower at least once weekly and as requested, but this was not adhered to. The Resident Council Meeting Minutes also indicated ongoing complaints about the lack of showers. Resident #1, with diagnoses including supra ventricular tachycardia, respiratory failure, and depression, was observed with body odor and unkempt hair. The resident reported receiving showers only once or twice a month, despite needing assistance from staff. Resident #2, with severe cognitive impairment and multiple health issues, also reported not receiving the required showers, leading to greasy hair and dirty sheets. Both residents expressed dissatisfaction with the frequency of showers and the lack of staff assistance. Similarly, Residents #4, #5, and #6, all with various medical conditions requiring assistance for bathing, reported receiving showers far less frequently than the expected twice a week. Observations confirmed their unkempt appearance and body odor. Interviews with these residents revealed that they often requested showers but were either ignored or given excuses by the staff. The facility administrator acknowledged the expectation for showers to be given at least twice a week and for refusals to be documented.
Facility Fails to Maintain Kitchen Equipment and Ensure Proper Food Storage
Penalty
Summary
The facility failed to repair essential kitchen equipment, including the convection oven, stove top burners, flat top grill, and oven. Observations revealed significant issues such as a wooden block holding up the stove, rust covering the inside of the oven, missing knobs, and debris buildup. Interviews with the Dietary Manager and cooks confirmed that the malfunctioning equipment slowed down meal preparation and made it challenging to cook meals efficiently. Despite informing the administration, the necessary repairs or replacements were not made, affecting the dietary staff's ability to perform their duties effectively. The facility also failed to ensure that food stored in residents' personal refrigerators was maintained at safe temperatures and that expired foods were discarded. Observations of several residents' refrigerators showed expired and improperly stored food items, including undated leftovers and uncovered containers. Interviews with residents indicated that no one regularly checked their refrigerators for expired food, temperature, or cleanliness. The Dietary Manager, housekeeping staff, and Director of Nursing provided conflicting information about who was responsible for these tasks, revealing a lack of a clear process or schedule for maintaining the refrigerators. The Administrator and Director of Operations acknowledged that housekeeping was supposed to check the temperatures, discard expired foods, and clean the refrigerators daily. However, the observations and interviews indicated that this was not being done consistently, leading to potential health risks for the residents. The facility's failure to maintain kitchen equipment and ensure proper food storage practices demonstrated significant deficiencies in their operations, potentially affecting all residents.
Failure to Develop a QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). The facility's policy, revised in February 2020, outlines the responsibilities of the QAPI committee, including overseeing the implementation of the QAPI plan, identifying and correcting quality deficiencies, and monitoring the effectiveness of corrective actions. However, the facility did not have a QAPI plan in place, despite having policies that describe the QAPI process. During an interview, the Administrator admitted that they are starting fresh with QAPI and could not find any past documentation. The facility has no Performance Improvement Projects (PIPs) in place and plans to have weekly QAPI meetings. The absence of a QAPI plan was confirmed through both interviews and record reviews, indicating a significant gap in the facility's quality assurance and performance improvement efforts.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility's policy required an ongoing, facility-wide, data-driven QAPI program focused on indicators of care outcomes and quality of life for residents. However, the review of the QAPI committee notes showed no evidence of key personnel such as the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, there were no Performance Improvement Projects (PIPs) in place, which are essential for addressing and correcting quality deficiencies. During an interview, the Administrator admitted that they were starting fresh with QAPI and could not find any past documentation of QAPI activities. Despite having a recent meeting, the facility had no PIPs in place and planned to have weekly QAPI meetings moving forward. This lack of documentation and absence of PIPs indicated a failure to systematically analyze underlying causes of systemic quality deficiencies and implement corrective actions, as required by their QAPI policy. This deficiency had the potential to affect all residents in the facility, which had a census of 92 at the time of the survey.
Failure to Maintain Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings with the required members. The facility's policy, revised in March 2020, mandates that the QAPI committee includes the Administrator, Director of Nursing Services, Medical Director, Infection Preventionist, and representatives from various departments. However, a review of an Inservice Log dated 04/26/24 showed no evidence of the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, the Administrator admitted to not finding documentation of past QAPI meetings and confirmed that no Performance Improvement Projects (PIPs) were in place. During interviews, the Administrator and Director of Operations acknowledged the expectation for the facility to hold QAPI meetings at least quarterly with the required members present. Despite the recent meeting, the lack of documentation and absence of key members indicate non-compliance with the facility's QAPI policy. The facility census at the time was 92 residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92. The facility's policy required that a Transfer to Another Facility form be filled out, explaining the reason for the transfer and the bed hold policy, and that this information be communicated to the resident or their representative. However, this procedure was not followed for the sampled residents, as there was no documentation of written notification to the residents or their representatives, nor was there any notification to the Ombudsman at the time of transfer to the hospital. The Social Services Director confirmed that they do not issue written transfer/discharge notices for hospital transfers, and the Administrator and Director of Operations stated that they would expect staff to notify the resident or their representative in writing and send a copy to the Ombudsman. Resident #2 was transferred to the hospital multiple times without written notification to the resident or their representative, and without notifying the Ombudsman. Similar deficiencies were found for Resident #4, who was transferred to the hospital on multiple occasions without the required notifications. Resident #11's medical record also showed a lack of documentation for written notification to the resident or their representative and the Ombudsman during a hospital transfer. Resident #14 experienced multiple hospital transfers without the necessary written notifications, and the same issue was found for Resident #52, who was transferred to the hospital three times without proper documentation. Other residents, including Resident #56, Resident #64, Resident #67, Resident #85, and Resident #444, also experienced hospital transfers without the required written notifications to themselves or their representatives and without notifying the Ombudsman. The facility's failure to follow its own policy and regulatory requirements for notifying residents, their representatives, and the Ombudsman in writing during hospital transfers was a consistent issue across multiple cases, as confirmed by interviews with the Social Services Director and the facility's administration.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency had the potential to affect all residents, with a facility census of 92. The nursing schedules from February 1, 2024, through April 30, 2024, revealed that there were 11 days without any RN scheduled. Specific dates without RN coverage included February 17, March 2, 3, 16, 17, 30, 31, and April 13, 14, 27, 28. During an interview on May 7, 2024, the Administrator acknowledged the expectation for RN coverage for at least eight hours a day, seven days a week. Additionally, the facility did not provide an RN coverage policy.
Failure to Notify Residents of Survey Results
Penalty
Summary
The facility failed to notify residents of the availability and location of the most recent survey results in an accessible location. This deficiency was identified during a resident council meeting where multiple residents collectively stated they were unaware of a binder containing survey results or its placement. The facility's census was 92 at the time. The Administrator admitted during an interview that the survey results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table, but this was after the deficiency was noted.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. For one resident, the medical record showed conflicting information with both full code and Do Not Resuscitate (DNR) statuses documented. The resident had a care plan that listed both statuses with corresponding interventions and goals. Interviews with the resident and staff revealed confusion about the resident's current code status, with the resident indicating a change from hospice to full code, which was not consistently reflected in the documentation. For another resident, the medical record also showed conflicting information with both full code and DNR statuses documented. The care plan listed a DNR status, but staff interviews revealed inconsistencies in how code statuses were communicated and documented. Certified Nurse Assistants (CNAs) and the Director of Nursing (DON) provided different methods for determining code status, including lists at the nurse's station and symbols on resident doors, leading to further confusion. The Administrator and Director of Operations confirmed that the code status should be consistently reflected throughout the resident's chart, which was not the case for these residents.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. Observations of a resident's room on multiple occasions revealed that the oxygen concentrator had debris on the filter and the left side of the concentrator. Additionally, there were twenty drywall patches on the walls and corners of the room that were not painted over. Another room was observed to have stained privacy curtains with a brown substance, and a different room had missing bottom drawers from the closet and bent trim. These observations indicate a lack of adherence to the facility's general cleaning procedure, which requires reporting dirty curtains, burnt-out light bulbs, and missing items to the housekeeping supervisor for maintenance repairs. During an interview, the Administrator and Director of Operations acknowledged that they would expect curtains to be clean and free from dirt, debris, and stains, oxygen concentrators to be cleaned weekly, and closets and drawers to be in working condition. They also stated that they would expect the walls of resident rooms to be free from drywall patches after maintenance has had a reasonable amount of time to paint over them. The failure to meet these expectations was evident in the observed conditions of the resident rooms, indicating a deficiency in maintaining a safe, clean, comfortable, and homelike environment for the residents.
Failure to Provide Adequate Discharge Documentation
Penalty
Summary
The facility failed to provide adequate discharge documentation for a resident transferred to another facility. Specifically, the facility did not include a discharge summary or recapitulation of the resident's stay, which is required to ensure a safe and effective transition of care. The facility's policy mandates that a discharge summary and post-discharge plan be developed, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. However, the medical record for the resident in question showed no such documentation upon their transfer to another facility. Interviews with facility staff revealed a misunderstanding or misapplication of the discharge policy. The Social Services Director indicated that discharge summaries are not typically filled out for residents transferred to another facility, and the Administrator confirmed this practice. The Director of Operations also stated that discharge summaries are only completed when a resident is discharged to go home, not when transferring to another nursing home. This practice is inconsistent with the facility's written policies and resulted in the failure to provide necessary discharge documentation for the resident.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents out of 19 sampled residents. The facility's policy required that the bed hold policy be explained and documented in writing upon obtaining a discharge order for hospital transfer. However, the medical records for the ten residents showed no documentation that the bed hold policy was communicated in writing during their transfers. This included multiple instances of hospital transfers and readmissions for each resident, with no written notification provided as required by the facility's policy. During interviews, the Social Services Director admitted that they do not issue a written copy of the bed hold policy to residents or their representatives when residents are sent to the hospital, as it was included in the initial admission package. The Administrator and Director of Operations stated that they expect staff to inform the resident or resident representative in writing of the bed hold policy upon hospitalization, indicating a discrepancy between the facility's policy and actual practice. This failure to provide written notification of the bed hold policy at the time of transfer was identified as a deficiency by the surveyors.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for two residents following their discharge from hospice services. For Resident #6, the medical record showed a quarterly MDS assessment indicating hospice services on 01/28/23 and a discharge from hospice services on an unspecified date. However, the facility did not complete a significant change MDS within 14 days after the discharge. Similarly, for Resident #67, the medical record showed a significant change MDS indicating the resident no longer received hospice services and a discharge date from hospice services, but the facility again failed to complete a significant change MDS within the required 14-day timeframe. During interviews, the Administrator, Director of Operations, and MDS Coordinator all acknowledged that the MDS should be updated and completed within the required timeframes as per the Resident Assessment Instrument (RAI) Manual. The MDS Coordinator specifically noted that a significant change MDS should be completed with each hospice admission and discharge to accurately reflect the resident's current condition. The failure to adhere to these requirements resulted in the deficiency noted in the report.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident #2's quarterly MDS assessment incorrectly indicated the use of insulin, despite no such order being present in the medical record. Resident #6's annual MDS assessment inaccurately marked Parkinson's disease and omitted diagnoses of GERD, macular degeneration, and glaucoma. Additionally, the quarterly MDS assessment for Resident #6 incorrectly indicated a life expectancy of less than six months following discharge from hospice services. Resident #9's quarterly MDS assessment incorrectly included a diagnosis of PTSD, which was not present in the medical record. Resident #64's quarterly MDS assessment failed to mark several diagnoses, including cardiac dysrhythmias, GERD, dementia, and anxiety. Resident #69's annual MDS assessment omitted diagnoses of heart failure, pneumonia, and Vitamin B-12 deficiency anemia. Interviews with facility staff, including the Social Services Director, Administrator, Director of Operations, and MDS Coordinator, confirmed the inaccuracies in the MDS assessments. The MDS Coordinator acknowledged that all active diagnoses should be reflected in Section I of the MDS and that non-insulin diabetes medication should not be coded as insulin. The facility's policy on MDS completion and submission timeframes, revised in October 2023, mandates that assessments be completed and submitted based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. The deficiencies indicate a failure to adhere to these guidelines, resulting in inaccurate documentation of residents' conditions.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of two residents. Resident #67, who was admitted with chronic kidney disease, cellulitis, GERD, insomnia, and heart failure, had orders for meropenem, normal saline flush, and PICC dressing changes. However, the care plan revised on 05/02/24 did not address the PICC line, which is a critical component of the resident's treatment plan. This omission indicates a lack of thorough analysis and updating of the care plan based on the resident's current medical needs and interventions as required by the facility's policy. Similarly, Resident #444, admitted with bacteremia, Type 2 diabetes, congestive heart failure, acute osteomyelitis, and a non-pressure chronic ulcer, had orders for daptomycin and PICC dressing changes. The care plan revised on 04/22/24 also failed to address the PICC line. During an interview, the Administrator and Director of Operations acknowledged that care plans should reflect the current condition of the resident and should be updated by facility staff when the responsible Registered Nurse is unavailable. This failure to update care plans as per the facility's policy resulted in deficiencies in the care provided to these residents.
Failure to Follow Physician's Orders and Obtain Treatment Orders
Penalty
Summary
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. Resident #11 had an order for levothyroxine to be taken every morning on an empty stomach, but the medication administration times ranged from 7:46 A.M. to 12:45 P.M., with the medication being administered late on 20 out of 64 days. Additionally, Resident #11 was observed wearing prevalon boots on multiple occasions without a treatment order for them. The Assistant Director of Nursing acknowledged the lack of an order for the boots and mentioned that staff sometimes remove them because they get hot and itchy. Resident #56 also had an order for levothyroxine to be taken every morning, but the medication administration times ranged from 7:01 A.M. to 12:34 P.M., with the medication being administered late on 30 out of 64 days. The resident's thyroid stimulating hormone (TSH) levels were abnormally high, indicating improper administration of the medication. Interviews with the Director of Nursing, a Licensed Practical Nurse, and a Certified Medication Technician confirmed that levothyroxine should be given on an empty stomach or at bedtime, and the resident's TSH labs supported that the medication was not being administered correctly.
Failure to Follow PICC Line Care Protocols
Penalty
Summary
The facility failed to ensure staff provided necessary care and services in accordance with professional standards of practice for two residents. For Resident #67, the staff did not follow policies and procedures regarding PICC line care and administration of IV antibiotics. The resident's PICC line dressing, dated 04/20/24, was not changed weekly as required, and the infusion was not disconnected or flushed promptly after completion. The Director of Nursing and an LPN were unaware of the resident's PICC line, indicating a lack of communication and oversight in the facility's care processes. For Resident #444, the staff also failed to adhere to PICC line care protocols. The resident's PICC line dressing, dated 04/24/24, was not changed weekly, and there was blood around the catheter site. An LPN experienced difficulty flushing the line, which was found to be pulled out approximately three centimeters and appeared kinked. The night nurse had accidentally pulled the line partway out during a dressing change, and the PICC line company had to be contacted to replace the line. The Director of Nursing confirmed that the staff should not attempt to reinsert a displaced PICC catheter. Interviews with the residents and staff revealed that the facility did not follow physician orders and professional standards for PICC line care. The Administrator and Director of Operations acknowledged that a registered nurse should complete PICC line dressing changes and that the line should be flushed and cared for according to physician orders. They also stated that infusions should be disconnected promptly after completion and that staff should not attempt to reinsert a displaced PICC catheter.
Failure to Screen Residents for Tuberculosis
Penalty
Summary
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. The policy mandates that all residents be screened for TB infection and disease, with specific guidelines for new admissions, readmissions, and annual screenings. However, the medical records of four residents showed lapses in compliance. Resident #4 was admitted on an unspecified date and had an annual TB test on 02/20/24, but there was no read date or documentation of TB testing or screening. Resident #11, admitted on an unspecified date, had their last annual screening on 01/19/23, with no subsequent documentation. Similarly, Resident #69 and Resident #444, both admitted on unspecified dates, had their last annual screenings on 01/19/23, with no further documentation of TB testing or screening since then. The facility's failure to adhere to its TB screening policy was identified through observation, interview, and record review. The policy requires annual risk assessments and regular testing for residents with specific health conditions or risk factors. Despite these requirements, the facility did not document the necessary TB screenings for the four residents, indicating a significant lapse in infection prevention and control measures. The facility's census at the time was 92, highlighting the potential for broader non-compliance issues within the resident population.
Inadequate Dining Room Space
Penalty
Summary
The facility failed to provide a dining room large enough to accommodate the residents, affecting one resident out of 19 sampled residents and three residents outside the sample, with the potential to affect all residents. Observations showed that the main dining room had 11 round tables with room for four chairs at each table, totaling 44 seating places, and one table with five residents. Additionally, an unknown staff member was observed squeezing between tables and bumping two residents' chairs while they were eating. The assisted dining room had 21 seating places, making a total of 65 seating places in the two dining rooms, which was insufficient for the facility census of 92 residents. Interviews with residents revealed dissatisfaction with the dining room arrangements. One resident mentioned taking food back to their room because the dining room was overcrowded. Another resident stated that the dining room was too full, causing some residents to leave and come back when a seat was available. A third resident expressed frustration over the inability to choose where to sit and noted that residents in wheelchairs were required to sit on one side of the dining room. The Director of Operations acknowledged that residents could eat in either dining room and that staff should be able to pass trays without bumping into residents, but the observations and resident interviews indicated otherwise.
Failure to Maintain Safe Overbed Lighting
Penalty
Summary
The facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures in three rooms. This practice was observed on multiple occasions, with items such as stuffed animals and crafts being placed on the light fixtures. These observations were made on different dates and times, indicating a recurring issue. The facility census was 92, and the deficient practice had the potential to affect all residents and staff in the facility. The facility did not have a specific policy for overbed lighting safety, although the facility's admission packet did include a rule against storing personal items on the overhead light fixture due to safety hazards. During an interview, the Administrator and Director of Operations acknowledged that items should not be placed on the light fixtures due to the potential fire hazard. Specific observations included three stuffed animals on the light over the bed in one room, two heart-shaped crafts in another, and various other items in additional rooms. These observations were consistent over two days, highlighting a lack of adherence to safety protocols and the facility's own rules and regulations regarding the storage of personal items.
Inadequate In-Service Education for CNAs
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year, affecting two out of two sampled Certified Nurse Assistants (CNA) D and E. CNA D, hired on 04/10/19, had only one hour of annual in-service training for the period from April 2023 through April 2024. Similarly, CNA E, hired on 03/11/19, had only four hours of annual in-service training for the same period. During an interview, the Administrator acknowledged that CNAs are expected to have at least twelve hours of in-service education per year. The facility did not provide an in-service training policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 92. Observations from 04/29/24 through 05/03/24 showed that the required daily nurse staffing information was not found near any of the nurse's stations or the main lobby where it would be easily visible to residents and visitors. During an interview on 05/03/24, a Certified Nurse Aide (CNA) stated that the daily nurse staffing information was posted in the nurse's office behind the nurse's station, making it inaccessible to residents or visitors. The Administrator confirmed on 05/07/24 that she would expect the facility staffing to be posted in a prominent location that is readily accessible to residents and visitors.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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