Maryville Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryville, Missouri.
- Location
- 524 North Laura, Maryville, Missouri 64468
- CMS Provider Number
- 265354
- Inspections on file
- 25
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Maryville Living Center during CMS and state inspections, most recent first.
A resident with cognitive impairment, stroke-related weakness, and mobility issues fell while attempting to get into bed and was returned to bed with a mechanical lift, but no thorough post-fall assessment was documented and the fall was not added to the care plan. Over the next several days, CNAs and therapy staff observed non-verbal signs of pain and leg swelling, and the family reported hip/leg pain, yet nursing documentation showed incomplete assessments, pain scores of 0, and no administration of ordered PRN acetaminophen. A mobile x-ray was ordered but delayed, and the resident was not sent to the hospital when the x-ray could not be obtained as planned; when imaging was finally completed, it revealed an acute right hip fracture, confirming that the facility failed to provide timely follow-up care and pain management after the fall.
A resident with atrial fibrillation, vertigo, and moderate cognitive decline reported having a large amount of cash upon admission. The SSD and a charge nurse counted over $2,000, after which the SSD secured most of the cash, along with a checkbook and bank cards, in an unsecured box in an office desk drawer and locked only the office door. By the next day, when the SSD went to retrieve the funds for the family, $600 in cash was missing, although the checkbook and bank cards remained. The facility’s investigation found that the desk drawer and box did not lock, the emergency key box for room keys in the medication room was found unlocked, and multiple staff had potential access to the SSD office key. A grievance was filed on behalf of the resident for the missing $600, and the resident was not reimbursed until weeks later.
A resident with severe cognitive impairment and total dependence for transfers was injured when a staff member failed to follow the care plan, using a gait belt instead of a mechanical lift with two staff as required. The improper transfer led to the resident being lowered to the floor and later diagnosed with a right lower leg fracture. Staff interviews confirmed that the correct procedures were not followed and that the aide did not check the care plan prior to the transfer.
A resident with dementia and impaired vision was served hot coffee by an LPN from an unauthorized coffee pot without a temperature check, in violation of facility policy. The resident, left unsupervised, spilled the coffee and sustained burns to the chest and abdomen, requiring wound care and additional medical treatment.
Two residents with cognitive impairment were subjected to physical abuse by another resident with a history of escalating behavioral issues, including hair pulling and being struck with a water pitcher, resulting in physical injury and distress. Staff and medical records confirmed the aggressive resident's ongoing agitation and prior incidents, but the facility did not prevent repeated access and harm to other residents.
Several staff members took unauthorized photos and a video of four residents, most with dementia, and shared them in a group chat on social media, including images with demeaning captions. The residents were unaware of being recorded, and staff violated facility policies on privacy, abuse prevention, and use of personal devices, despite having received relevant training.
A resident with dementia was hit by a CMT in the face during an incident in the SCU. Despite facility policy, the CMT remained in contact with the resident for over 2.5 hours before being removed. Staff interviews revealed confusion about reporting procedures, contributing to the delay in addressing the abuse.
The facility failed to maintain a sanitary kitchen, with unclean surfaces, improper food storage, and incomplete cleaning logs. Food temperatures were not consistently checked, and sanitation procedures were not followed, including improper handwashing and lack of sanitizer use. The facility also lacked a policy for dating and labeling foods, leading to undated items in storage.
The facility failed to respect the rights of six residents by not providing adequate grooming and privacy. Three residents were not groomed properly, with facial hair not being shaved regularly despite their preferences and needs. Additionally, the facility did not respect the privacy of three residents, with personal care instructions being visible to others and blood sugar checks being conducted in the hallway.
The facility failed to honor the choice of two residents regarding their wake-up times, as care plans did not specify their preferences. One resident with cognitive impairment was left waiting in a wheelchair despite expressing a desire to lay down, while another resident with severe cognitive impairment and pressure ulcers was not consulted about their schedule. Staff interviews revealed a lack of communication and documentation regarding residents' preferences, leading to a deficiency in honoring their rights.
The facility failed to address grievances and recommendations from the resident council, affecting all residents involved. Residents were unaware of the grievance process and expressed concerns about care issues like cold food and long call light response times. The facility did not document attempts to resolve these concerns, and staff interviews revealed inconsistencies in the grievance process.
The facility failed to inform residents about the grievance process, resulting in unaddressed concerns about food quality, call light response times, and bathing schedules. Residents were unaware of how to file grievances, and staff interviews revealed inconsistent knowledge and follow-up on grievances. A family member reported a lack of follow-up on grievances, and grievance reports lacked documentation of resolution or notification to complainants.
The facility failed to create individualized care plans for two residents, neglecting to address dehydration, falls, and code status. One resident, with a history of falls and dehydration, lacked specific interventions in their care plan despite recent incidents. Another resident's care plan did not reflect their DNR status. Staff interviews confirmed these issues should have been care planned.
The facility failed to administer medications within the appropriate time frame for three residents. A resident received Levothyroxine late due to staff cleaning delays, while another resident's multiple medications, including Levothyroxine and Ropinole, were administered late. Additionally, a third resident's Gabapentin was given past the scheduled time. The DON acknowledged the delays, noting that medications should be administered within one hour of their scheduled time.
The facility failed to provide necessary assistance with ADLs, affecting four residents. Two residents did not receive regular showers, and two others did not receive complete incontinence care. Observations showed residents with unkempt appearances and improper cleaning techniques by staff. Interviews revealed insufficient staffing and lack of dedicated shower aides.
The facility failed to ensure residents were free from accident hazards and provided with adequate supervision. A resident was not served the correct therapeutic diet, another had medication left unattended, and improper techniques were used during a sit-to-stand lift transfer, causing discomfort and potential risk of injury.
The facility experienced significant staffing shortages, leading to multiple deficiencies in resident care. A resident with severe cognitive and mobility impairments did not receive regular showers, and meal services were consistently delayed, affecting all residents. Medications were administered late, and the Activity Director was often pulled to cover staffing gaps, resulting in canceled activities. The facility lacked policies for staffing and showers, contributing to these issues.
The facility had a medication error rate of 32.14%, with staff failing to follow manufacturer guidelines for insulin administration, not removing a Lidocaine patch on time, and improperly crushing medications. Additionally, eye drop administration did not adhere to policy, affecting multiple residents.
The facility failed to secure medication carts, leaving them unlocked and unattended, and did not properly manage medications for a resident with severe cognitive impairment. Additionally, an expired Influenza Vaccine was not discarded, and a Lactulose Solution lacked a pharmacy label. These deficiencies were observed despite existing policies requiring secure storage and proper labeling of medications.
The facility failed to provide adequate dietary staffing, resulting in delayed meal service and unsanitary kitchen conditions. Observations showed meals were served late, and the kitchen was unclean with incomplete cleaning logs. Staff reported high turnover and insufficient training, contributing to the issues.
The facility failed to serve food at safe and appetizing temperatures, as observed in a sample of residents. Hot foods were served below the required 120 degrees Fahrenheit, with items like fish and carrots falling short. Residents reported dissatisfaction with food temperatures and quality, noting cold hot foods and unappetizing meal appearances. Despite expectations from dietary staff to maintain proper temperatures, these were not met, resulting in the deficiency.
Two residents in a facility were found with inaccessible call lights, despite their care plans and staff expectations. One resident, with severe cognitive impairment and mobility issues, had the call light out of reach, requiring family intervention. Another resident, with dementia and impaired vision, was observed multiple times with the call light on the floor or hanging out of reach, necessitating leaving the bed to seek help. Staff interviews confirmed the expectation for call lights to be within reach, highlighting a failure to meet this standard.
A facility failed to protect residents' privacy when an LPN left a medication cart computer screen unattended and visible with resident information accessible. This occurred multiple times, with the screen left open in public areas. Interviews confirmed that staff were expected to lock or shut down screens when unattended, as per facility policy.
A resident with a left hip fracture and dementia developed a Stage II pressure ulcer on the left heel, which was not identified by the facility staff until discovered by the family. The facility failed to conduct timely skin assessments and implement preventive measures, despite the resident being bedridden and requiring assistance for transfers. Interviews confirmed that the resident was not admitted with the ulcer, and weekly skin assessments were not completed as required.
The facility failed to serve meals according to residents' dietary needs, with staff not following recipes or using correct portion sizes. Observations showed inconsistent meal preparation, with incorrect ingredients and serving utensils used. Interviews revealed staff did not adhere to menu guidelines, leading to potential nutritional deficiencies for all residents.
A resident with dementia and malnutrition was served food inconsistent with their dietary orders, receiving regular bacon and scrambled eggs instead of the prescribed minced and moist diet. Despite staff awareness and in-service education, incorrect diets were an ongoing issue, with the dietary manager acknowledging the problem and emphasizing the importance of following physician-ordered diets to prevent choking.
A resident with severe cognitive impairment and multiple care needs was not provided care in a manner that prevented infection, as staff failed to wash hands between dirty and clean tasks. Observations showed that a CNA, LPN, CMT, and NA did not adhere to hand hygiene protocols during care, despite the resident being on enhanced barrier precautions. Interviews revealed inconsistencies in staff understanding and implementation of handwashing practices.
Failure to Timely Assess, Manage Pain, and Obtain Evaluation After Resident Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up care, assessment, and pain management after a resident sustained a fall and subsequently was found to have a right hip fracture. The resident had significant cognitive deficits, stroke with right-sided weakness, COPD, and TIA, and was dependent on staff for toileting and bathing. The care plan identified the resident as at risk for falls with walking and balance problems and specified that the resident should not be left alone in the wheelchair or bathroom and should have the call light within reach, but the fall that occurred on 02/10/26 and the resident’s pain were not added to the care plan. After the fall, documentation showed the resident was found on the floor near the bed after attempting to get into bed and was transferred back to bed with a mechanical lift. Following the fall, there was no documented post-fall assessment on the day of the incident, and subsequent nursing notes did not include complete assessments of gait, grasp, or upper and lower extremity movement. CNA and therapy staff reported the resident was grunting, groaning, grimacing, and turning red with movement, and that the leg appeared swollen, but these observations were not reflected in the nursing documentation. Pain assessments recorded on the MAR for several days after the fall consistently showed a pain score of 0 on all shifts, and no acetaminophen or other pain medication was administered, despite family reports of pain and therapy staff concerns. The facility’s policies required assessment and treatment of injuries after a fall, notification of the practitioner for accidents or new pain, and support of residents’ right to optimal pain assessment and management, including recognition of non-verbal expressions of pain. When the resident’s family reported pain in the right leg/hip area, an order was obtained for a mobile x-ray of the right hip. The mobile x-ray service was unable to perform the x-ray as initially scheduled and delayed it until the following day, yet the resident was not sent to the hospital that night despite ongoing pain complaints. Nursing notes during this period still lacked complete assessments of lower extremity movement. The x-ray ultimately showed an acute right hip fracture, and the resident was then sent to the hospital by ambulance. Interviews with staff revealed that therapy had notified an LPN about the resident’s pain and that multiple CNAs had reported pain complaints after the fall, but nursing staff did not treat the pain or promptly arrange hospital evaluation when mobile x-ray was unavailable, resulting in several days without appropriate pain management or timely diagnostic follow-up.
Failure to Safeguard Resident Funds Resulting in Missing Cash
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s money from misappropriation after it was placed under the facility’s control. A resident with atrial fibrillation, vertigo, and moderate cognitive decline (BIMS score of 8) was admitted and reported having cash in a purse. The Social Services Designee (SSD) and a charge nurse counted $2,137 in cash, along with a checkbook and three bank cards. The resident chose to keep $20, and the SSD took the remaining $2,117 in cash, plus the checkbook and bank cards, and placed them in a box in a desk drawer in the SSD office. The SSD documented the amount in a progress note and notified the resident’s family to pick up the money and valuables. The SSD reported that the box used for storage was in a desk drawer and that neither the box nor the drawer locked. After placing the money and valuables in the box, the SSD left for the day, locking only the SSD office door. The next day, the SSD returned to work, was in and out of the office, and later went to retrieve the money to give to the resident’s family. At that time, the SSD observed that the cash was not in the same position as previously placed, and upon recounting, discovered that $600 was missing, leaving $1,517. The checkbook and bank cards remained in the box. The SSD confirmed that the Administrator and DON had keys to the SSD office and that an additional SSD office key was kept in an emergency key box in the medication room, to which nurses and certified medication technicians had access. The facility’s own investigation documented that the safe box and desk drawer in the SSD office did not lock and that the emergency key box in the medication room was found unlocked, with the zip lock seal missing, while the SSD key was still present inside. Staff working during the relevant time frame were interviewed and denied knowledge of the missing money or accessing the SSD office. A grievance was filed on behalf of the resident stating that $600 went missing while being held in the SSD office. Law enforcement was notified and obtained details from the Administrator and SSD about how the money was acquired, stored, and later found to be short. The facility did not reimburse the resident for the missing $600 until several weeks after the incident, despite the money having gone missing while in the facility’s custody and control.
Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when facility staff failed to follow a resident's care plan during a transfer, resulting in the resident sustaining a right lower leg fracture. The resident, who had severe cognitive impairment and was dependent on staff for all transfers and activities of daily living, was care planned to require a mechanical lift with the assistance of two staff members for all transfers. Despite this, a nursing aide attempted to transfer the resident using only a gait belt and without the required mechanical lift or a second staff member present. The aide was not aware of the resident's transfer requirements and did not check the care plan prior to the transfer, stating that they did not have time to look up the information. During the transfer, the aide was unable to safely move the resident and had to lower them to the floor. At the time, no immediate signs of injury were noted, and the resident was assisted back to bed. However, the following morning, the resident was found to have swelling, bruising, and pain in the right ankle, which was subsequently diagnosed as a fracture of the distal tibia and fibula. The resident's care plan and facility policy both clearly indicated the need for mechanical lift transfers with two staff, and this information was accessible in the electronic medical record and care plan documentation. Interviews with staff revealed that the majority were aware of the proper procedures for transferring residents who require mechanical lifts, including the need for two staff members and the prohibition of using gait belts for such residents. The aide involved in the incident admitted to not checking the care plan and not being familiar with the resident's specific needs. Other staff present at the time confirmed that the correct transfer method was not used, and that the aide had been advised to use the mechanical lift but did not comply.
Failure to Follow Hot Beverage Policy Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure a safe environment and adequate supervision for a resident with moderate cognitive impairment, dementia, impaired vision, and a need for assistance with activities of daily living. The facility's hot beverage policy required that coffee and hot water be cooled to 130 degrees before serving to residents, and that only dietary staff provide hot beverages after checking the temperature. However, a staff member brought a personal coffee pot to the nursing station, and an LPN served hot coffee to the resident without checking its temperature, in violation of the policy. The resident, who had diagnoses including dementia, seizure disorder, and anxiety, requested coffee and a snack. The LPN provided the coffee, which the resident subsequently spilled on their chest and abdomen while unsupervised. The incident resulted in burns, with progress notes documenting reddened areas, blisters, and wounds to the chest and abdomen. The resident required wound care, including cleansing, application of antibiotic ointment, and dressings, as well as additional supplements and medications as ordered by the provider. Interviews and record reviews confirmed that the coffee pot was not authorized, the temperature of the coffee was not checked, and the resident was left unsupervised. Staff interviews revealed that the hot liquid policy was in place prior to the incident, but not followed. The resident's care plan and medical records indicated a need for supervision and assistance, which was not provided at the time of the incident, directly leading to the resident's injury.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents on the Memory Care Unit from physical abuse by another resident. One resident, who had moderate cognitive loss and a history of verbal and physical behaviors, became increasingly agitated and aggressive over a period of weeks. This resident pulled another resident's hair and later struck a different resident, who was also the spouse, with a full water pitcher, causing physical injury and mental distress. Staff interviews and medical record reviews confirmed that the aggressive resident had exhibited escalating behaviors, including yelling at staff, throwing objects, and physical altercations with other residents. The first incident occurred when a resident with extensive cognitive loss and no prior behavioral issues was walking out of the dining room and interacted with the aggressive resident's spouse. The aggressive resident responded by yanking the other resident's hair and pulling them down. The second incident involved the aggressive resident entering the spouse's room and striking them in the head with a water pitcher, resulting in abrasions and redness. Staff members heard distress sounds and intervened, but not before the aggressive resident made contact multiple times. The spouse was found in a defensive posture, and the aggressive resident was removed from the room. Medical records and staff interviews indicated that the aggressive resident had a documented history of behavioral problems, including physical aggression toward staff and other residents, and had been seen by psychiatric professionals for increased agitation. Despite these known risks, the resident was able to access and harm other residents on multiple occasions. The facility's failure to prevent these incidents resulted in physical and psychological harm to the affected residents.
Staff Shared Unauthorized Resident Photos and Videos on Social Media
Penalty
Summary
The facility failed to protect four residents from abuse when three staff members took unauthorized photos and one staff member took a video of the residents and posted them to social media. Two of the images included demeaning comments about the residents. The residents involved had varying degrees of cognitive impairment, with three diagnosed with dementia and some unable to understand or consent to being photographed or recorded. All four residents were unaware that their images had been captured or shared online. The staff involved used a Snapchat group chat to share these images and videos among themselves. The group included five nurse aides, and the content was shared without the knowledge or consent of the residents or their legal representatives. In some cases, the residents were depicted in vulnerable situations, such as wearing only a hospital gown or being the subject of derogatory captions. The facility's policies explicitly prohibited the use of personal devices to take photos or videos of residents and required staff to respect residents' privacy and dignity at all times. Interviews and record reviews confirmed that the staff had received training on abuse prevention, HIPAA, and the facility's cell phone and social media policies. Despite this, the staff members involved knowingly violated these policies. Some staff admitted to recognizing the actions as violations but failed to report them promptly. The incident was eventually reported by one staff member, leading to an internal investigation. The residents' cognitive limitations and inability to provide informed consent were significant factors in the deficiency, as was the staff's disregard for established protocols regarding resident privacy and abuse prevention.
Failure to Protect Resident from Abuse and Delay in Reporting
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Medication Technician (CMT) hit the resident in the face with an open hand. This incident occurred in the Special Care Unit (SCU) and involved a resident with significant cognitive loss, dementia with psychosis, and other conditions that required moderate assistance for activities of daily living. The resident was found on the floor by the CMT, and during the process of assisting the resident back to bed, the CMT reacted by smacking the resident across the face when the resident was swinging arms and kicking. Despite the facility's policy that mandates immediate removal of any alleged perpetrator from resident contact, the CMT remained in direct contact with the resident for over 2.5 hours after the incident. The incident was not reported to the Charge Nurse until nearly two hours later, and the CMT was not removed from the facility until the MDS Coordinator arrived and found the CMT still in the resident's room. The MDS Coordinator admitted to not instructing the Charge Nurse to remove the CMT from resident care, which was a mistake. Interviews with staff revealed a lack of clarity and training on reporting procedures for abuse. Both the Nurse Aide and Certified Nurse Aide involved in the incident were unsure of the proper steps to take and who to report the abuse to. The Director of Nursing and the Administrator were not informed of the incident until later, and the Administrator was unaware that the CMT had remained in contact with the resident until arriving at work. The facility's failure to immediately remove the CMT from resident contact and the delay in reporting the incident contributed to the deficiency.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed by surveyors. The kitchen was found to have unclean surfaces, including tables that had not been cleaned after breakfast, a trash can lid with food residue, and a stove top with burnt food residue. Additionally, the steam table contained food particles, and the microwave was not clean. The dry storage room had spilled food items, and the walk-in cooler had eggs stored directly on the floor. The kitchen floors were littered with food particles, and there were no paper towels available at the handwashing sink. The facility's cleaning logs were incomplete, with no entries for several days, and the monthly cleaning schedule had no entries at all. The facility also failed to adhere to proper food temperature protocols. Staff did not take food temperatures on the steam table before service, and foods were not reheated to safe temperatures before serving. Observations showed that chicken fritters, minced meat, and macaroni were added to the steam table without temperature checks. Baked beans were reheated in the microwave but not temperature checked before being added to the steam table. The dietary manager and staff did not consistently document food temperatures, and some foods were not held at appropriate temperatures during meal service. Furthermore, the facility did not follow proper sanitation procedures. Clean cups were stored upright, and there was no thermometer in the refrigerator unit. The three-compartment sink was not properly sanitized, with test strips showing 0 parts per million of sanitizing solution. Staff did not wash their hands after contamination, and there were no sanitizer buckets prepared in the kitchen. The facility lacked a policy for dating and labeling foods, resulting in undated and unlabeled food items in storage. Staff also failed to wash hands between handling dirty and clean dishes, and there were no paper towels available for handwashing.
Deficiencies in Resident Grooming and Privacy
Penalty
Summary
The facility failed to respect the rights of six residents by not providing adequate grooming and privacy. Three residents were not groomed properly, with facial hair not being shaved regularly despite their preferences and needs. For instance, one resident with severe cognitive impairment was observed with facial hair on their chin, which was not consistently shaved during shower opportunities. Another resident, who was also severely cognitively impaired, expressed discomfort with their facial hair, yet it was not addressed by the staff. Additionally, the facility did not respect the privacy of three residents. One resident had their blood sugar checked in the hallway, which is against the facility's protocol. Another resident had a sign on their bathroom door detailing personal care instructions, including their name, which was visible to anyone entering the room. Similarly, another resident had multiple signs in their room detailing their care instructions, which were visible to other residents and visitors. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that the facility's expectations were not met in these instances. Staff acknowledged that residents should be groomed regularly and that personal care instructions should not be visible to others. The facility also lacked a dignity policy, which contributed to these deficiencies in respecting resident rights.
Failure to Honor Resident Choice in Wake-Up Times
Penalty
Summary
The facility failed to ensure that residents were offered a choice of when they would like to get up in the morning, affecting two residents. Resident #30, who had moderate cognitive impairment and required substantial assistance, was observed sitting in a wheelchair at the nurse's station early in the morning, expressing a desire to lay down. Despite the resident's repeated requests, no staff responded promptly. Interviews revealed that staff were unaware of the resident's preferences, and the care plan did not specify the resident's desired wake-up time. Resident #43, with severe cognitive impairment and a history of pressure ulcers, was also affected. The resident was dressed and seated in a wheelchair at the nurse's station early in the morning. The care plan did not address the resident's preferred wake-up time, and the staff generally aimed to have residents up by 7:00 A.M. Interviews indicated that the resident's family was not consulted about their preferences, and the care plan lacked specific instructions regarding the resident's schedule. Interviews with staff, including the DON and ADON, highlighted a lack of communication and documentation regarding residents' preferences for wake-up times. The facility's policy emphasized resident self-determination, but the care plans did not reflect this, leading to a deficiency in honoring residents' rights to choose their daily schedules.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not adequately addressing grievances and recommendations made by the resident council. The facility did not maintain documentation of resident concerns, attempts to resolve these concerns, or follow-up actions. This affected all residents serving on the resident council and potentially other residents in the facility. During interviews, residents expressed that they were unaware of how to complete a grievance, did not have access to grievance forms, and did not know who the grievance officer was. They also raised concerns about showers not being given, tough meat, cold food, and long wait times for call lights, which resulted in incontinence and feelings of humiliation. The review of resident council minutes from April to June 2024 showed repeated concerns about food quality, call light response times, and other issues, with no documentation on how or if these concerns were addressed. Interviews with facility staff, including the Social Services Designee, Certified Nurse Aide, Administrator, and Director of Nursing, revealed inconsistencies in the grievance process and a lack of awareness among staff about the procedure. The Social Services Designee mentioned that grievances were located by the front door and that they would fill out grievances for residents if requested. However, there was no evidence that grievances were discussed in resident council meetings, and the facility's policy and goal to resolve issues within five days were not documented as being met.
Failure to Inform and Resolve Resident Grievances
Penalty
Summary
The facility failed to adequately inform residents about the grievance process, resulting in residents being unaware of how to file grievances or complaints. During a group interview, residents expressed that they did not know how to complete a grievance, lacked access to grievance forms, and were unaware of the grievance officer's identity or where to submit a grievance form. Additionally, concerns raised in resident council meetings, such as issues with food quality, call light response times, and bathing schedules, were repeatedly voiced over several months without resolution or follow-up. The facility's grievance policy was not effectively communicated or implemented, as evidenced by the lack of education on the grievance process during resident council meetings and the absence of documented resolutions for grievances. Interviews with staff, including the Social Service Designee and a Certified Nurse Aide, revealed a lack of knowledge about the grievance process and inconsistent follow-up on grievances. Furthermore, the facility's grievance reports for a specific resident's family member showed incomplete documentation, with no indication of resolution or notification to the complainant. The facility's failure to address grievances effectively was further highlighted by a family member's statement that grievances were not followed up on, leading to a lack of trust in the grievance process. The Administrator and Director of Nursing acknowledged that grievances should be discussed at resident council meetings, but this was not being done. The facility's grievance forms did not require signatures from residents or family members to confirm satisfaction with resolutions, indicating a gap in the grievance handling process.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for two residents, leading to deficiencies in addressing dehydration, falls, and code status. Resident #15, who was severely cognitively impaired and dependent on a walker, had a history of falls and dehydration but did not have these issues addressed in their care plan. Despite having a fall on 4/14/24 and being hospitalized for acute kidney injury and dehydration on 4/15/24, the care plan lacked specific interventions for these conditions. Interviews with facility staff, including the MDS Coordinator, Director of Nursing, and Assistant Director of Nursing, revealed an expectation that such issues should have been care planned. Resident #44, also severely cognitively impaired, had a DNR order signed on 8/23/22, but this was not reflected in their care plan as of 6/4/24. The resident's annual MDS indicated severe cognitive impairment and various diagnoses, including dementia and anxiety, but the care plan failed to address the resident's code status. Interviews with the MDS Coordinator, Director of Nursing, and Assistant Director of Nursing confirmed that code status should have been included in the care plan. The facility's policy on comprehensive care planning emphasizes the need for individualized plans with measurable goals and time frames, which should be revised as changes occur in a resident's condition. However, the facility did not adhere to this policy for Residents #15 and #44, resulting in deficiencies related to the lack of care planning for falls, dehydration, and code status. The facility census at the time was 59.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure that medications were administered within the appropriate time frame, affecting three residents. Resident #28 was prescribed Levothyroxine to be administered at 5:00 A.M. for hypothyroidism, but it was documented as being administered late at 7:33 A.M. The Director of Nursing (DON) was observed administering the medication at 7:32 A.M. after initially being delayed by staff cleaning the resident. Resident #21 had multiple medications prescribed, including Levothyroxine and Ropinole, which were also administered late. The medications were due at 5:00 A.M. but were given at 7:45 A.M. The DON acknowledged the delay, stating that the medications were early morning doses. Similarly, Resident #29 was prescribed Gabapentin to be administered at 6:00 A.M., but it was documented as being administered at 7:47 A.M. The DON confirmed that medications should be passed within one hour before or after they were due.
Deficiencies in ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for residents who required it, specifically in the areas of bathing and incontinence care. This deficiency affected four out of 17 sampled residents. Two residents did not receive regular showers, and two others did not receive complete incontinence care. The facility's policies on perineal care and resident rights were reviewed, but no policy on showers was provided. Resident #4, who had no cognitive impairment and required partial assistance with personal hygiene, was observed with greasy and uncombed hair, wearing the same clothes for consecutive days. The resident reported not receiving regular showers, with records showing infrequent showers over several months. Interviews with staff revealed a lack of dedicated shower aides and insufficient staffing to ensure regular showers for residents. Resident #43, with severely impaired cognitive skills and requiring substantial assistance with ADLs, also did not receive regular showers. Family members reported the resident received a shower approximately once a week, sometimes after two weeks. Incontinence care for Residents #33 and #40 was inadequately performed, with staff failing to follow proper procedures for cleaning and using the same area of wipes or washcloths for different skin areas. Interviews with staff confirmed these improper practices and acknowledged the need for correct cleaning techniques.
Deficiencies in Resident Care and Supervision
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and provided with adequate supervision to prevent accidents. Specifically, Resident #27 was not served the correct therapeutic diet as ordered by the physician. Despite having a diagnosis of dementia and dysphagia, the resident was repeatedly served the wrong type of meat, which was not minced and moist as required. This issue was observed multiple times, and the Speech Language Pathologist (SLP) had to intervene to correct the diet. The dietary staff and kitchen personnel were aware of the resident's dietary needs but failed to consistently follow the prescribed diet orders. Resident #49, who was severely cognitively impaired, had a controlled medication, clonazepam, left on a card table in their room for two days. The medication was not administered as per the physician's orders, and there was no documentation of missed doses. The facility's policy required staff to remain with the resident while they took their medication, but this was not followed, leading to the medication being left unattended. This oversight was contrary to the facility's inservice training, which emphasized that medications should not be left in resident rooms. Additionally, the facility did not use proper techniques during the use of a sit-to-stand lift for Resident #43, who required substantial assistance with transfers. The lift pad slid up past the resident's armpits during a transfer, causing discomfort and potential risk of injury. The staff did not follow the manufacturer's guidelines for the lift, which included keeping the legs of the lift open for stability and ensuring the brakes were locked when raising or lowering the resident. The resident expressed pain during the transfer, indicating improper handling by the staff.
Staffing Shortages Lead to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, resulting in several deficiencies. One resident, who required substantial assistance with activities of daily living due to severe cognitive impairment and mobility issues, did not receive regular showers. The resident's shower schedule was inconsistent, with significant gaps between showers, and family members reported that they often had to request showers after two weeks without one. Interviews with staff revealed that there was no dedicated shower aide, and the responsibility was assigned to aides on the halls, leading to missed showers when staff were unavailable. Additionally, the facility experienced delays in meal service, affecting all residents. Observations showed that meals were consistently served late, with lunch trays being delivered and served well after the scheduled times. Staff interviews indicated that the delays were often due to insufficient staffing, with only two staff members available to assist residents to the dining room. This shortage also impacted other aspects of care, such as timely administration of medications and the ability to lay residents down after meals. The facility also failed to provide timely medication administration for several residents. Medications that were scheduled for early morning administration were given late, as observed during the survey. The Director of Nursing was seen administering medications hours after they were due, citing staffing issues as a reason for the delay. Furthermore, the Activity Director was frequently pulled from their role to cover staffing shortages on the floor, resulting in canceled activities for residents. The facility did not provide policies for staffing or showers, contributing to the deficiencies observed.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 32.14% due to nine errors out of 28 opportunities. This affected five residents, including those who received insulin injections not administered according to manufacturer guidelines. Specifically, the Assistant Director of Nursing (ADON) did not hold the insulin needle in the skin for the required six seconds, as observed with two residents. The ADON admitted to counting only three or four seconds, contrary to the manufacturer's instructions. Additionally, the facility did not adhere to proper procedures for transdermal patch application and removal. A Licensed Practical Nurse (LPN) failed to remove a Lidocaine patch from a resident's hip at the designated time, leaving it on overnight. The patch was supposed to be removed after 12 hours, but it was not dated, timed, or initialed, indicating a lapse in following physician orders and facility policy. The facility also did not follow proper procedures for medication administration, including crushing medications that should not be crushed. A Certified Medication Technician (CMT) crushed several medications, including Metformin ER and multivitamins, which should have been administered whole. Furthermore, the CMT did not apply lacrimal pressure after administering eye drops to a resident, as required by the facility's policy and manufacturer guidelines.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely, as observed on multiple occasions where medication carts were left unlocked and unattended. Registered Nurse (RN) and Licensed Practical Nurse (LPN) were seen leaving medication carts unlocked in various areas, such as the dinette and hallway, without any staff in visual contact. This occurred despite the facility's policy requiring medication carts to be locked when unattended. Interviews with the nursing staff confirmed that they were aware of the requirement to lock the carts but failed to do so consistently. Additionally, the facility did not properly manage medications for a resident with severe cognitive impairment. The resident, who was on antipsychotic, antianxiety, and antidepressant medications, was found to have a clonazepam tablet left unsecured in their room. The medication administration record showed a missed entry for clonazepam, and the resident had no assessments to self-administer medications. This oversight was acknowledged by the LPN, who confirmed the pill belonged to the resident and should not have been left in the room. The facility also failed to discard an expired vial of Influenza Vaccine and did not ensure a bottle of Lactulose Solution had a pharmacy label. The Director of Nursing (DON) confirmed that the expired vaccine should have been discarded and that the Lactulose should have been labeled with the resident's name. These lapses in medication management were identified during an observation and interview in the medication room, highlighting a lack of adherence to proper medication storage and labeling protocols.
Inadequate Dietary Staffing and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to provide adequate staffing in the dietary department, leading to delays in meal service and unsanitary kitchen conditions. Observations revealed that meals were consistently served late, with lunch trays being delivered and served well past the posted meal times. Residents reported that meals were often delayed by at least 30 minutes. The facility's open dining policy was not adhered to, as evidenced by the late delivery and serving of meals in both the memory care unit and the dining room. The kitchen was found to be in an unsanitary state, with unclean tables, food residue on various surfaces, and a lack of proper cleaning and maintenance. The cleaning logs were incomplete, with no entries for several days and weeks, indicating a failure to follow the facility's cleaning schedules. The dietary manager and staff reported high turnover and insufficient staffing, which contributed to the inability to maintain cleanliness and timely meal service. The dietary manager also lacked prior food service experience and adequate training, further exacerbating the issues. Interviews with staff highlighted the challenges faced due to the workload and lack of training. The dietary aide position was difficult to fill, and new employees often left shortly after starting due to the demands of the job. The dietary manager expressed the need for additional help and training to effectively manage the department. The facility did not provide a policy regarding dietary staffing, which may have contributed to the ongoing issues in the dietary department.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature to three residents out of a sample of fifteen. The facility's policy required hot foods to be at least 120 degrees Fahrenheit when served, but several food items were found to be below this temperature during a meal test tray observation. For instance, fish was served at 99.2 degrees, carrots at 111.9 degrees, and baked beans at 104.6 degrees, all below the required serving temperature. Resident interviews highlighted dissatisfaction with the food temperatures and quality. One resident reported that hot food was typically cold, and cold food was too warm, while another resident mentioned that their food was cold. Additionally, the appearance and texture of the meals were noted to be unappetizing, with overcooked vegetables and soggy chicken nuggets. The dietary manager and dietician both expressed expectations that staff should ensure food is served at the correct temperature, with procedures in place to reheat food if necessary. However, these expectations were not met, leading to the deficiency.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for residents in their rooms, as observed in the cases of two residents. Resident #43, who had severe cognitive impairment, impaired mobility, and a history of falls, was found with the call light draped over the foot of the bed, out of reach. Despite the resident's care plan indicating the need for the call light to be within reach at all times, staff left the room without ensuring the call light was accessible, requiring family intervention to rectify the situation. Resident #44, who was severely cognitively impaired and had multiple health issues including dementia and impaired vision, was observed multiple times with the call light on the floor or hanging out of reach. This resident, who was at risk for falls, had to leave the bed to seek assistance, indicating a failure to provide the necessary accessibility to the call light. Staff did not ensure the call light was within reach even after assisting the resident back to bed. Interviews with various staff members, including a Registered Nurse, Licensed Practical Nurse, Certified Nurse Aide, MDS Coordinator, Director of Nursing, Assistant Director of Nursing, and the Administrator, all confirmed the expectation that call lights should be within residents' reach. Despite this, the observations showed a consistent failure to adhere to this standard, as evidenced by the repeated instances of inaccessible call lights for the two residents.
Breach of Resident Privacy Due to Unattended Computer Screen
Penalty
Summary
The facility failed to protect residents' personal privacy when a Licensed Practical Nurse (LPN) left the medication cart computer screen unattended, unlocked, and visible with resident personal information accessible to anyone nearby. This occurred multiple times on the morning of June 11, 2024, with the computer screen being left open and visible to resident confidential information for several minutes at a time. The LPN left the medication cart unattended while entering various rooms and the dining area, leaving the computer screen exposed in a public area. Interviews with the LPN and the facility's Director of Nursing (DON) and Assistant DON revealed that the staff was expected to lock the computer screen or shut it down when leaving the medication cart unattended to protect residents' privacy. The facility's policy on electronic medical records and resident rights emphasized the importance of maintaining confidentiality and preventing unauthorized access to resident information. Despite these policies, the LPN did not adhere to the expected procedures, resulting in a breach of resident privacy.
Failure to Identify and Document Pressure Ulcer
Penalty
Summary
The facility failed to identify, assess, and document a pressure ulcer for Resident #43, who was admitted with a left hip fracture and dementia. Upon admission, the resident's skin integrity was noted to have a surgical wound, but no other skin issues were documented. However, on 1/26/24, it was noted that the resident had developed a Stage II pressure ulcer on the left heel, which was not identified until the resident's family member discovered it. The ulcer measured 5 cm x 4 cm with a black center and serous drainage, indicating a lack of timely skin assessment and documentation by the facility staff. The resident's medical records and progress notes revealed that the resident had been primarily bedridden since admission and required assistance for transfers. Despite this, the facility did not implement adequate preventive measures such as heel protectors or regular repositioning to prevent pressure ulcers. The resident's condition was further complicated by cognitive impairment, requiring substantial assistance with daily activities, and the presence of a suprapubic catheter, which increased the risk of skin breakdown. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A confirmed that the resident was not admitted with a pressure ulcer on the left heel, and the weekly skin assessments were not completed as required. The DON acknowledged that the nurses should have identified the wound before the family did, indicating a lapse in the facility's wound care and prevention protocols. This deficiency highlights the facility's failure to adhere to its own policies for ongoing skin assessment and pressure ulcer prevention, leading to the development and progression of the resident's pressure ulcer.
Failure to Follow Dietary Guidelines and Portion Sizes
Penalty
Summary
The facility failed to ensure that meals were served according to the nutritional needs and dietary requirements of the residents. Observations revealed that staff did not follow the prescribed recipes and portion sizes as outlined in the facility's menu. Specifically, during meal preparation, staff did not use the correct ingredients or follow the recipes for minced and moist diets, and they failed to use the appropriate serving utensils, resulting in inconsistent portion sizes. This inconsistency in meal preparation and serving had the potential to affect all residents in the facility. Interviews with staff members, including the dietary manager and the dietician, confirmed that there was a lack of adherence to the menu and recipe guidelines. Staff members admitted to not using the menu book for preparing meals and instead relied on their own judgment or previous instructions from former managers. This led to incorrect portion sizes being served, with some residents receiving more or fewer pieces of chicken than specified in the menu. Additionally, the dietary manager acknowledged that prior to their tenure, staff were unaware of the location of the recipe book, indicating a lack of proper training and oversight. The dietary manager and dietician both expressed expectations that staff should follow the recipes and use the correct serving utensils as indicated in the menu. However, the staff's failure to do so resulted in meals that did not meet the nutritional needs of the residents. The administrator also expected adherence to the menu and recipe guidelines, but the observations and interviews highlighted a significant gap between these expectations and the actual practices in the kitchen.
Failure to Adhere to Dietary Orders for Resident
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs, specifically for Resident #27, who was served food inconsistent with their dietary orders. Resident #27, who had a diagnosis of dementia and mild protein-calorie malnutrition, was on a therapeutic diet requiring minced and moist level 5 meats. However, observations revealed that the resident was served regular bacon and scrambled eggs instead of the prescribed minced and moist diet. This discrepancy was noted by the speech language pathologist (SLP), who intervened to correct the meal. Further observations showed that the resident was again served the wrong diet at lunch, receiving pureed meats instead of the ordered minced and moist meats. Interviews with staff, including the SLP, dietary manager, and certified nurses aides (CNAs), indicated that serving incorrect diets was an ongoing issue within the facility. The dietary manager acknowledged awareness of the problem and emphasized the importance of following physician-ordered diets to prevent choking incidents. Interviews with various staff members, including the Director of Nursing (DON) and Assistant DON, revealed a general expectation that dietary orders should be followed accurately. Despite in-service education provided to staff on ensuring correct diet orders, the issue persisted, with staff admitting to occasionally serving incorrect diets. The facility's failure to consistently adhere to dietary orders resulted in Resident #27 being served inappropriate meals, highlighting a significant deficiency in dietary management.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by staff not washing their hands between dirty and clean tasks. This deficiency was observed during interactions with a resident who had severe cognitive impairment, required substantial assistance with daily activities, and had a suprapubic catheter and a Stage II pressure ulcer. The resident was on enhanced barrier precautions due to these conditions, which necessitated strict adherence to infection control protocols. During observations, it was noted that a CNA and an LPN did not wash their hands between glove changes while providing care to the resident. The LPN removed gloves after cleaning the resident's coccyx and applied new gloves without washing hands. Similarly, a CMT and another NA also failed to wash their hands between glove changes while assisting the resident with transfers and personal care. These actions were contrary to the facility's handwashing policy, which, although undated, aimed to reduce the transmission of organisms. Interviews with staff, including the DON, revealed a lack of consistent understanding and adherence to hand hygiene protocols. Staff members acknowledged the importance of washing hands when entering a resident's room, between glove changes, and after providing care, especially when dealing with fecal material. However, the observed practices did not align with these expectations, indicating a gap in the implementation of infection control measures.
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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