New Mark Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 11221 North Nashua Drive, Kansas City, Missouri 64155
- CMS Provider Number
- 265308
- Inspections on file
- 33
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at New Mark Rehab And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe, comfortable environment when both boilers malfunctioned, causing indoor temperatures to drop below the facility’s stated 71–81°F range. Several residents with conditions such as CHF, multiple sclerosis, dementia, chronic respiratory failure, and depression reported very cold rooms and described needing to wear coats, mittens, gloves, sweaters, and extra blankets indoors to stay warm. Some residents were offered moves to warmer rooms, but others were not offered relocation or extra blankets, despite the facility’s extreme weather policy requiring comfort measures during cold conditions. Observations confirmed cool rooms, non-functioning or inadequately heating room units, and residents bundled in outerwear and blankets while in bed or in their rooms.
A resident with multiple cardiac, cognitive, and functional diagnoses was moved from the facility to another SNF within the same company without a physician discharge order, required discharge notice, or completed discharge documentation in the medical record. The facility’s policy required advance written notice of transfer/discharge, including reasons, effective date, destination details, appeal rights, and Ombudsman information, to be provided to the resident and their representative, and for discharge planning and documentation to be maintained. Instead, staff communicated discharge plans with a family member who was not the resident’s DPOA, while the designated DPOA reported not being notified of the discharge, not receiving any discharge paperwork or notice, and not being contacted by or signing admission paperwork for the receiving facility. The DON stated that staff were expected to notify and obtain agreement from the DPOA or provide a 30‑day notice, and the Administrator acknowledged that no discharge notice was completed because staff believed the move to another SNF was a transfer rather than a discharge.
Licensed staff and the SSD failed to document critical clinical information and to administer or properly document medications as ordered. A resident with ESRD on hemodialysis, diabetes, CHF, atrial fibrillation, chronic infected wounds, and intact cognition had a critical potassium level reported from an outside clinic; the clinic ordered hospital transfer, the resident refused, and an NP ordered high-dose oral KCl and STAT labs, yet none of these events, refusals, code status changes, or missed dialysis/IV antibiotic treatments were documented in the clinical record. On a separate day, three other residents had multiple medications and nutritional supplements marked on the MAR with a code directing staff to see progress notes, but the notes did not explain why medications were not given, and some doses were not documented as administered at all. Staffing issues contributed when a CMT called off, an RN unfamiliar with LTC med passes attempted to cover while managing other clinical duties, and many scheduled medications were not administered or explained in the record.
A facility failed to report an alleged incident of sexual abuse between two residents to law enforcement and the state survey agency within the required timeframe, despite its own policy and federal regulations. The incident involved a resident with severe cognitive impairment and another resident with a history of inappropriate sexual behavior. Staff and family were aware of the allegation, but administration decided not to report it after reviewing camera footage and assessments, and the hospice agency was not notified by the facility.
A facility failed to follow its abuse prevention policy by not conducting a documented investigation or notifying authorities after an allegation that a resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate sexual behavior. Despite staff and family reports of the incident and the facility's own policy requirements, the Administrator determined the allegation was unsubstantiated without a formal investigation or external reporting.
A resident with a surgical wound and multiple health conditions had a wound vac dressing left unchanged for an extended period due to missing physician orders and unclear staff responsibilities. When the dressing was finally removed, it was severely adhered to the wound, causing significant bleeding and requiring hospital transfer. Staff interviews confirmed a lack of documentation and confusion about wound care procedures.
A resident with severe cognitive impairment and a history of wandering exited the secure memory care unit, was found in the parking lot with a head laceration, and required hospital evaluation. Staff were aware of the resident's exit-seeking behaviors but did not prevent the elopement, resulting in injury.
A resident with complex medical and behavioral needs was transferred to a hospital after an incident of aggression, but facility staff failed to provide the required written discharge notice, bed hold policy, and information on appeal rights to the resident or their representative. There was no evidence of involvement of the resident or representative in discharge planning, and communication among staff and with the hospital was lacking, resulting in confusion and harm to the resident.
A resident with a history of behavioral issues and neurocognitive disorders physically assaulted another resident with dementia, resulting in multiple injuries including facial scratches, bruising, and emotional distress. Staff discovered the incident after hearing screaming, and the facility's policies requiring intervention and abuse prevention were not effectively implemented to prevent the altercation.
During a recent survey, multiple food safety and hygiene protocol deficiencies were observed. Stored food items in the walk-in freezer and refrigerator were found undated and exposed to potential contamination. Additionally, air vents in the kitchen were visibly dirty, posing a risk of contaminating food with dust particles. The Dietary Director acknowledged the importance of proper labeling and dating but noted a lack of awareness among maintenance staff regarding vent cleanliness. Furthermore, a dietary staff member was observed not wearing a beard restraint while handling food, contrary to facility policy. The staff member cited discomfort as the reason for removing the restraint, indicating a gap in adherence to established hygiene guidelines. These deficiencies could potentially impact the health and safety of the 98 residents consuming food prepared in the facility's kitchen.
The facility failed to inform a resident and/or their representative of the risks and benefits of a physician-ordered antipsychotic medication. The resident, who had moderate cognitive impairment, was not aware of the purpose of the medication, and no consent was documented. The Unit Manager confirmed the lack of consent, and the facility did not provide a relevant policy.
The facility failed to maintain a clean and comfortable environment for a resident, who was observed to have a build-up of dirt and grime, dust, and ants in the room. Despite the resident's cognitive intactness, the room's condition remained poor over multiple observations. The Administrator was unaware of the ant issue, and the Activity Director acknowledged that spring cleaning had not started and there was no care plan addressing the resident's wishes and the need for room cleaning.
A resident with cognitive impairments bit another resident after the latter reached for a blanket, despite staff being aware of the aggressive behaviors and having interventions in place. The biting incident resulted in a bruise but no broken skin. Staff separated the residents and placed the aggressor on 15-minute checks.
The facility failed to report an injury of unknown origin and a resident-to-resident altercation to the SSA within the required timeframes. A resident with dementia was found with a bruise, and another resident was involved in an altercation, both of which were not reported promptly as per facility policy.
The facility failed to investigate an injury of unknown origin and a resident-to-resident altercation involving two residents. One resident was found with a bruise below her eye, and another was hit on the arm by another resident. No investigations were conducted as required by the facility's policy.
The facility failed to update the care plans for two residents. One resident with PTSD did not have a care plan addressing this condition, and another resident using a specialized wheelchair did not have this equipment included in their care plan. These oversights could lead to inappropriate care and services.
The facility failed to provide appropriate support for a resident's head and leg while in a wheelchair and delayed obtaining a dermatology appointment for another resident with excessive itching. These deficiencies were confirmed through observations, staff interviews, and record reviews.
A resident with a history of stroke and cerebral palsy did not receive appropriate services to maintain or improve her range of motion (ROM). Despite having functional limitations, the resident did not receive any restorative therapy or exercises, and the only intervention was the placement of a washcloth in her contracted hand. Staff confirmed that the resident had not been assessed for restorative exercises, and there was no designated nurse responsible for the restorative program.
The facility failed to properly store a resident's nebulizer tubing and pipe, leaving them uncovered on a bedside table. This oversight was confirmed by an LPN and placed the resident, who had COPD and required frequent nebulizer treatments, at risk for infection.
The facility failed to complete an AIMS assessment for a resident on antipsychotic medication and did not have a stop date or diagnosis for a PRN psychotropic medication for another resident. These oversights placed the residents at risk for unrecognized side effects and diminished quality of life.
The facility failed to remove an expired insulin pen from a medication cart, leading to its use on a resident with high blood sugar. The RN confirmed the pen was expired, and the DON stated that expired pens should be removed. The facility's policy and manufacturer's guidelines were not followed.
The facility failed to maintain the reach-in refrigerator in the kitchen, which had been leaking for at least six months, affecting 98 of the 99 residents who consume food from the kitchen. Despite being noted in the Maintenance Repair Log in August 2023, the issue was not repaired, and the maintenance staff was only notified about the leak recently.
Failure to Maintain Comfortable Indoor Temperatures During Heating System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable, and homelike environment when the heating system could not sustain comfortable temperatures for residents. The facility had a policy titled “Extreme Weather” dated 08/25/23, which stated that during extreme cold weather the facility would provide extra blankets to residents who desired them, obtain additional warm clothing for residents with insufficient warm clothing, provide additional warm beverages, and have staff assess residents for comfort and take additional measures as necessary. The policy also required the Maintenance Department to maintain a log of facility temperatures and document measures taken if temperatures fell below 71°F or above 81°F. Despite this policy, the heating system malfunctioned, and the facility did not consistently implement measures such as relocation or provision of extra blankets for all affected residents. One resident with lymphedema, repeated falls, asthma, depression, atrial fibrillation, and bilateral knee osteoarthritis, and with intact cognition per a BIMS score of 15, reported that it was very cold in the facility on a Sunday. This resident stated that the room was very cold, requiring extra blankets and a coat, and that staff later offered and completed a move to a warmer room on a different hall. The resident reported that no one had followed up about when they could return to the original room and that it was still too cold in the facility, requiring continued use of a coat and blanket while outside the room. Another resident with multiple sclerosis, dementia, cognitive communication deficit, and bipolar disorder, with moderately impaired cognition (BIMS score 12), reported that their room was very cold, that staff asked them to move rooms but they declined due to concern about leaving belongings unattended, and that they had to wear a coat, mittens, and an extra blanket to keep warm. Observation confirmed the room was very cool, the resident was in bed wearing a coat and mittens, and the in-room heating unit was not blowing air and had a blank control panel screen that did not respond to the on/off switch or temperature buttons. A third resident with polyneuropathy, type 2 diabetes mellitus, chronic respiratory failure, weakness, and major depressive disorder, and intact cognition (BIMS score 14), stated that it had gotten “pretty cold” in the room. This resident reported that staff did not offer another room to move to temporarily or offer additional blankets, and that they would have moved to sleep in a warmer room. The resident said the heating unit was working but did not blow very warm air, and that maintenance had checked it that morning without explaining what was done. Observation showed this resident wearing a coat, gloves, and blankets. A fourth resident with CHF, alcohol-induced persisting dementia, tachycardia, seizures, major depressive disorder, and GAD, and moderately impaired cognition (BIMS score 12), reported that the room was very cold overnight, that the heating unit felt like it was blowing cool air, and that they had to wear a sweater, coat, and gloves to stay warm. This resident stated that staff did not offer a move to a warmer room or extra blankets and that they would have moved temporarily if given the choice. A CMT reported working on the Sunday when the building became very cold, especially on one hall, due to a problem with the heating system. The CMT stated that some residents in affected rooms were offered moves to warmer rooms, two residents agreed to move, and two chose to stay, but the CMT did not know why all affected residents were not offered room changes. The Maintenance Director reported that one of the two boilers stopped working over the weekend and that while technicians were working on it, the second boiler also stopped working. The Maintenance Director acknowledged that temperatures in the facility became cool on that Sunday and again on the day of the survey, and noted that one resident room temperature had been 68°F that morning. The Maintenance Director stated they had been resetting individual heating units in resident rooms and that temperatures were returning to normal. The DON and Administrator both stated expectations that the facility temperature remain within 71–81°F, that residents should not need to wear mittens inside, and that residents should be relocated to warmer areas and offered extra blankets if rooms were too cold. Despite these stated expectations and the written policy, multiple residents experienced cold rooms, wore coats, gloves, and blankets indoors, and some were not offered relocation or additional blankets, demonstrating the failure to provide a safe and comfortable environment during the heating system failure.
Failure to Provide Required Discharge Notice and Documentation for a Resident Transferred to Another SNF
Penalty
Summary
The deficiency involves the facility’s failure to provide a required discharge notice, follow appropriate discharge procedures, and complete discharge documentation for a resident who was moved to another skilled nursing facility. The facility had a written Transfer and Discharge policy requiring that residents be transferred or discharged only under specific conditions, based on a physician order (unless leaving against medical advice), and that reasonable advance notice—typically 30 days—be given to the resident and their representative, with certain exceptions. The policy also required that a written notice of proposed transfer/discharge be provided to the resident and their representative, containing the reason for discharge, effective date, destination information, appeal rights, and Ombudsman contact information, and that a copy be sent to the State Long Term Care Ombudsman for facility-initiated discharges. Documentation related to discharge, including a discharge summary and post-discharge plan, was to be maintained in the medical record. The resident at issue was admitted from a hospital and later discharged to another skilled nursing facility within the same company. The resident had multiple diagnoses, including fluid overload, atrial fibrillation, cognitive communication deficit, repeated falls, lack of coordination, dementia with behavioral disturbance, heart disease, and urinary incontinence. An admission MDS showed adequate hearing, clear speech, ability to make self-understood and understand others, and a BIMS score of 10 indicating moderately impaired cognition, with no behaviors noted during that assessment. The comprehensive care plan included interventions for smoking-related lung function, ADLs, behaviors related to inappropriate sexual comments, communication, cardiac status, edema/fluid overload, cognition related to dementia, fall risk, mood problems related to new long-term care admission, nutrition, skin integrity, and bladder incontinence. The resident had a Durable Power of Attorney (DPOA) document naming a family member (Family Member A) as the Power of Attorney for financial, contractual, medical, legal, and personal matters. Despite these requirements and the identified DPOA, the facility did not obtain or document a physician order to discharge the resident to another skilled nursing facility, and the electronic medical record lacked a discharge notice, discharge summary, discharge care plan, or physician orders related to the discharge and admission to the receiving facility. Progress notes showed that on one date the Social Services Designee spoke with a family member who was not the DPOA to update them on the resident’s discharge progress, and later the Admissions Director documented that the resident would discharge to another skilled facility within the company on a specified day and time, with transport arranged, personal effects sent with the resident and family, and current documentation and discharge order to be sent. However, the DPOA (Family Member A) reported not being notified of the discharge, not receiving any discharge paperwork or discharge notice, and not being contacted by or signing admission paperwork for the receiving facility, and stated they would not have chosen that facility. The DON stated an expectation that staff notify the DPOA/representative, obtain approval or give a 30‑day notice, and ensure the accepting facility could meet the resident’s needs. The Administrator acknowledged that a discharge notice was not completed because staff believed the move to another skilled nursing facility was a transfer rather than a discharge, even though social services was responsible for discharge planning documentation and providing discharge notices as required by regulation. There was no indication in the record that, once the failure to provide a discharge notice was identified, the facility subsequently administered a discharge notice to the resident or the resident’s representative. The lack of required notice, absence of a physician discharge order, and missing discharge documentation in the medical record, combined with communication directed to a non‑DPOA family member instead of the designated DPOA, formed the basis of the deficiency identified by surveyors.
Failure to Document Critical Clinical Events and Administer Medications as Ordered
Penalty
Summary
The deficiency involves failures by licensed nursing staff and the social services designee (SSD) to document critical changes in a resident’s condition and treatment, as well as failures by nursing staff to administer and/or document medications as ordered for multiple residents. One resident with intact cognition, end-stage renal disease on hemodialysis three times weekly, insulin-dependent diabetes, chronic infected wounds with osteomyelitis, prior lower extremity amputation, atrial fibrillation, and congestive heart failure had a critical potassium level reported from an outpatient clinic. The clinic physician ordered that the resident be sent to the emergency room for treatment. RN A was notified of the critical lab and the order to send the resident to the hospital, spoke with the resident who refused transfer, and then contacted the facility nurse practitioner, who ordered an immediate 80 mEq dose of oral potassium and a STAT repeat potassium level. None of these events, including the resident’s refusal of hospital transfer, the new treatment plan, the STAT lab order, or the subsequent STAT lab results and provider notification, were documented in the resident’s clinical record. For this same resident, the SSD completed a change in code status to Do Not Resuscitate (DNR) but did not document this interaction or other extensive contacts with the resident in the clinical record, instead keeping notes in a separate notebook. The SSD recalled the resident expressing a wish to change to DNR status after discussions with dialysis nurses, and a new DNR was completed, but there was no corresponding documentation in the facility chart. Additionally, there was no documentation that the dialysis clinic or physician were notified when the resident refused a scheduled hemodialysis treatment, which also included IV antibiotic therapy, nor was the missed dialysis/antibiotic treatment documented as such. Nursing progress notes around the time of the critical potassium result and subsequent events contained only limited entries (e.g., repositioning, offering water, and the time the resident was found without respirations and pulse), with no record of the critical lab, treatment decisions, refusals, or communication with outside providers. The deficiency also includes failures to administer and/or document medications as ordered for three other residents. For one resident with multiple cardiac and nutritional medications, the MAR showed that on a specific date all ordered medications and supplements were marked with a code "9" (indicating to see progress notes), but the progress notes contained no explanation for why the medications were not administered. For another resident with numerous psychotropic, cardiac, pain, GI, and nutritional orders, the MAR likewise showed all medications and supplements coded "9" on a specific date, with no corresponding documentation in the progress notes explaining the omissions; in addition, gabapentin, buspirone, and Med Pass were not documented as administered at scheduled times. A third resident had ordered diltiazem three times daily and a nutritional supplement four times daily; on a specific date, both were coded "9" on the MAR, and a progress note explicitly stated that neither the medication nor the supplement had been administered. Staff interviews further clarified the circumstances leading to the missed medications. The staffing coordinator reported that on the day in question a Certified Medication Technician (CMT) called in for the 100 halls, and despite attempts to find in-house or agency coverage, no replacement was obtained until 2:00 p.m. RN B, who had never previously passed medications in LTC, was instructed to begin passing medications while coverage was sought. RN B reported difficulty with medication administration, including not knowing which medications required crushing or mixing with food, and being simultaneously responsible for a resident with a medical emergency, wound care, and monitoring residents for falls or altercations. RN B acknowledged that some medications were passed but not all, and that when the CMT arrived at 2:00 p.m., the CMT declined to administer the overdue medications and told RN B to document them as not administered. RN B stated that if medications were not passed, he or she should have documented in the progress notes why they were not administered, but this was not done.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to follow its own abuse prevention policy and federal and state regulations by not reporting an alleged incident of sexual abuse involving a resident to law enforcement and the state survey agency within the required two-hour timeframe. The policy clearly mandates immediate reporting of suspected abuse, including sexual abuse, to the appropriate authorities, but this was not done in this case. The incident involved one resident allegedly attempting to put their hands down another resident's pants in a common area, as witnessed by staff and other residents. The resident who was the alleged victim had significant cognitive impairment, including diagnoses of senile degeneration of the brain, dementia with agitation, and major depressive disorder. The resident required assistance with activities of daily living and exhibited behaviors such as yelling and agitation. The alleged perpetrator also had cognitive deficits and a history of making inappropriate sexual comments, and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy, the incident was not reported to the state survey agency, law enforcement, or the hospice agency caring for the resident. Interviews revealed that staff were aware of the incident and that the family of the alleged victim was notified. However, the facility's administration determined, after reviewing camera footage and conducting assessments, that the incident did not occur as initially reported and therefore did not report it to authorities. The hospice agency only became aware of the incident after being informed by the resident's family, not by the facility. The failure to report the allegation as required constitutes the deficiency.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not ensure that an alleged incident of sexual abuse involving a resident was properly investigated. According to the facility's policy, all allegations of abuse, including sexual abuse, must be promptly and thoroughly investigated, with appropriate notifications made to authorities and documentation of all investigative steps. However, when an allegation was made that one resident put their hands down another resident's pants in a common area, the facility did not conduct a documented investigation as required by policy. The Administrator relied on a review of camera footage, which was later stated to be unavailable, and determined the allegation was unsubstantiated without further inquiry or reporting to the state survey agency or law enforcement. The resident involved in the alleged incident had significant cognitive impairment, as evidenced by a BIMS score of zero and diagnoses including dementia with agitation, senile degeneration of the brain, and major depressive disorder. The resident was also receiving hospice services and required assistance with activities of daily living. The alleged perpetrator had a history of making inappropriate sexual comments and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy requiring investigation and reporting, the Administrator did not initiate a formal investigation or notify external authorities. Interviews with staff and the resident's family revealed inconsistencies in the facility's response. The family was informed by nursing staff that the incident had been witnessed by others and that an assessment found no injuries or signs of distress. However, the Administrator later stated there was no camera footage and that the incident did not warrant reporting or further investigation. The lack of a documented investigation and failure to follow established protocols resulted in a deficiency related to the facility's handling of abuse allegations.
Failure to Obtain and Follow Wound Vac Dressing Orders Resulting in Harm
Penalty
Summary
The facility failed to ensure that appropriate wound dressing orders were obtained and followed for a resident with a left below-the-knee amputation and multiple comorbidities, including Parkinson's Disease and peripheral vascular disease. The resident had a negative pressure wound therapy (wound vac) applied to the surgical site, but there were no documented physician orders for wound vac changes between September 9 and September 16. During this period, the wound vac dressing remained in place for ten days without being changed, contrary to standard practice and the facility's own wound management policy, which requires treatment per physician order and regular skin assessments. When staff attempted to change the wound vac dressing, they found the sponge severely adhered to the wound, resulting in significant bleeding and pain for the resident. The lack of documentation regarding dressing changes and absence of a wound nurse contributed to confusion among staff about wound care responsibilities and supply ordering. The incident led to the resident being transferred to the hospital due to excessive bleeding. Interviews with clinical staff and providers confirmed that the dressing was not changed as expected and that there were no clear orders or documentation guiding wound care during the period in question.
Failure to Prevent Elopement and Injury in Cognitively Impaired Resident
Penalty
Summary
A resident with a history of traumatic brain injury, subdural hemorrhage, dementia with behavioral disturbances, and other significant medical conditions eloped from the facility's secure memory care unit. The resident was known to have severely impaired cognition, required substantial assistance with activities of daily living, and had a documented risk for elopement and wandering. On the day of the incident, the resident was observed to be agitated, demanding to go home, and was last seen at the nurse's station before propelling a wheelchair down the hallway, transferring out of the wheelchair, and exiting through a door that sounded an alarm. Shortly after, the resident was found in the facility parking lot by visitors, sitting on the ground with a laceration to the forehead. Staff responded, brought the resident back inside, and the resident was subsequently sent to the emergency room for evaluation due to the head injury and history of anticoagulant use. The resident returned later with sutures to the forehead and additional bruising, but imaging was negative for further injury. Interviews with staff and practitioners confirmed that the resident was known for frequent wandering and exit-seeking behaviors, and staff were expected to monitor the resident and respond to door alarms. The deficiency occurred due to the facility's failure to provide adequate supervision and prevent the resident from eloping, despite the resident's known risks and behaviors. The resident was able to leave the secure unit, exit the building, and sustain an injury before being found and assisted by staff.
Failure to Provide Required Discharge Notice and Documentation
Penalty
Summary
A deficiency occurred when facility staff failed to provide an appropriate discharge for a resident with complex medical and behavioral needs. The resident, who had diagnoses including congestive heart failure, neurocognitive disorder with Lewy bodies, repeated falls, dementia, and was on hospice care, was transferred to a hospital following an incident of severe agitation and aggression. Staff attempted de-escalation techniques, but after the resident struck a staff member and exhibited exit-seeking behavior, the DON called 911 for a hospital transfer. The family was notified of the transfer for medical evaluation, but there was no clear communication that the resident would not be accepted back to the facility. The facility did not provide the required written notice of discharge, which should have included the date and location of discharge, a statement of appeal rights, and contact information for the State Long Term Care Ombudsman. Documentation of the bed hold policy was not found in the electronic records, and the family confirmed they did not receive a copy of the bed hold policy, notice of proposed transfer/discharge, or information regarding appeal rights. The resident's DPOA was not notified of the transfer or discharge, and there was no evidence of the resident or representative's involvement in the development of a discharge plan addressing the resident's needs. Interviews with facility staff revealed confusion and lack of coordination regarding the discharge process. The Social Services Director had little involvement and was notified after the transfer occurred, while the Admissions Coordinator was unaware that the resident would not return to the facility. The DON and LPN involved in the transfer did not communicate the final discharge decision to the family or DPOA. The hospital staff were also not informed that the resident would not be returning, and the hospital was not equipped to provide long-term care. As a result, the resident experienced confusion, physical and psychosocial harm due to the lack of appropriate planning and notification.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another, resulting in multiple injuries. Specifically, a resident with a history of behavioral problems, including hitting and pulling peers' hair, and diagnoses such as frontal temporal neurocognitive disorder, dementia, depression, and Pick's disease, hit and restrained another resident. The assaulted resident, who had Alzheimer's disease and dementia, sustained a scratch to the left cheek, redness to the right eye, an abrasion to the right eyebrow, and redness and bruises to the right forearm and bicep. The incident occurred in a resident room and was discovered by staff after hearing screaming; staff did not witness the altercation but found the injured resident visibly shaken and crying. The care plan for the resident who initiated the altercation noted a behavior problem and directed staff to intervene as necessary to protect others, but the incident still occurred. Both residents involved had significant cognitive impairments, and the resident who was assaulted had a history of trauma and poor safety awareness. The facility's Abuse Prevention and Prohibition Program outlined a zero-tolerance policy for abuse and required staff to prevent abuse and monitor resident behaviors that could lead to conflict. Despite these policies, the altercation resulted in physical harm, and the injuries were confirmed by the DON and Administrator as fitting the definition of physical abuse according to facility policy.
Food Safety and Hygiene Protocol Deficiencies Identified
Penalty
Summary
The facility failed to ensure compliance with food safety standards during a survey conducted on 04/08/24. Observations revealed multiple instances of stored food items being undated and exposed to potential contamination in the walk-in freezer and refrigerator. Additionally, air vents in the kitchen were visibly dirty, posing a risk of contaminating food with dust particles. The Dietary Director acknowledged the importance of proper labeling and dating of food items but noted a lack of awareness among maintenance staff regarding the cleanliness of the vents. Furthermore, during the same survey, a dietary staff member was observed not wearing a beard restraint while handling food on the serving line, contrary to facility policy requiring staff to wear appropriate hair restraints at all times. The staff member admitted to removing the restraint due to discomfort, highlighting a gap in adherence to established guidelines for preventing hair contamination in food preparation areas. These deficiencies in food storage practices and staff compliance with hygiene protocols could potentially impact the health and safety of the 98 residents consuming food prepared in the facility's kitchen.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of a physician-ordered antipsychotic medication. Specifically, Resident 78, who was admitted with Alzheimer's disease and major depressive disorder, was prescribed Abilify 5 mg at bedtime. The resident's electronic medical record did not document that the resident or her representative was informed of the risks and benefits prior to initiating the new medication order. This oversight was confirmed during an interview with the Unit Manager, who acknowledged that no consent was obtained for the use of the medication. Resident 78 had a Brief Interview of Mental Status score indicating moderate cognitive impairment and was administered the antipsychotic medication daily. During an interview, the resident stated she was not aware of what Abilify was for, despite being administered the medication. The facility did not provide a policy regarding the documentation of informed consent for medication use, highlighting a significant lapse in ensuring residents are fully informed about their treatments.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for Resident 67, who was observed to have a heavy build-up of dirt and grime in the sliding door track, dirt and dust under the bed, and small black ants in the room. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15 out of 15, the room's condition remained poor over multiple observations. The resident and a family member both noted the presence of ants and the need for better cleaning. The facility's Administrator was unaware of the ant issue, and the Activity Director, who oversees housekeeping, acknowledged that spring cleaning had not yet started and there was no care plan addressing the resident's wishes and the need for room cleaning. During interviews, the Administrator mentioned that exterminators visit every other week and weekly in late spring and summer. The Activity Director stated that they had not begun spring cleaning tasks such as steam cleaning and moving furniture. The lack of a care plan to balance the resident's preferences with the need for cleanliness contributed to the ongoing issue. The facility's failure to address the cleanliness and pest control in Resident 67's room led to the deficiency noted in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, bit Resident 51 on the arm after Resident 51 reached for a blanket that Resident 96 was using. Both residents have significant cognitive impairments, with their respective care plans noting aggressive and socially inappropriate behaviors. Despite interventions to monitor and manage these behaviors, the incident occurred, resulting in a bruise on Resident 51's arm, although the skin was not broken. Interviews with staff revealed that Resident 96 was known to be uncooperative with care, often becoming combative when staff attempted to take something away from her. Staff had been using strategies such as offering sweets and drinks to redirect her, but these were not always effective. On the day of the incident, Resident 96 was lying on a couch in the common area, a place she preferred to stay during the day. When Resident 51 reached for the blanket, Resident 96 reacted by biting her. Staff immediately separated the residents and placed Resident 96 on 15-minute checks. Further interviews indicated that staff were aware of Resident 96's unpredictable behavior and had been trying to keep a close eye on her. The Director of Nursing mentioned that Resident 96 had been sent out for psychiatric evaluation following the incident. The facility's policy on abuse and neglect emphasizes the residents' right to be free from all forms of abuse and outlines procedures for reporting and addressing such incidents. However, the measures in place were insufficient to prevent the incident from occurring, highlighting a deficiency in protecting residents from abuse by other residents.
Failure to Report Injury and Altercation Timely
Penalty
Summary
The facility failed to report an injury of unknown origin and a resident-to-resident altercation to the State Survey Agency (SSA) within the required timeframes. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, was found with a bruise below her left eye on 10/24/23. The Licensed Practical Nurse (LPN) who discovered the bruise did not remember reporting it to the Director of Nursing (DON) or completing a report. The DON also did not recall the incident and confirmed it was not reported to the SSA as required. Additionally, an altercation occurred on 03/20/24 where Resident 96 was hit by another resident. This incident was reported to the unit manager but not to the DON until the following morning. The DON was unaware that such incidents needed to be reported within two hours if they did not result in major injury. The incident was eventually reported to the SSA on 03/22/24. The facility's policy mandates reporting all incidents of potential abuse, neglect, exploitation, or potential crimes against residents within prescribed timeframes, but this was not adhered to in these cases.
Failure to Investigate Injury and Altercation
Penalty
Summary
The facility failed to conduct thorough investigations for an injury of unknown origin and a resident-to-resident altercation involving two residents. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, was found with a small purplish bruise below her left eye while sitting in the TV area. The resident was unable to explain how the bruise occurred and denied pain. The Licensed Practical Nurse (LPN) who discovered the bruise did not remember reporting it to the Director of Nursing (DON) or completing a report. The DON confirmed that no investigation was conducted to determine the cause of the bruise. Resident 51, diagnosed with Alzheimer's and dementia, was involved in an altercation where another resident was observed hitting her on the right arm. The incident was reported to the unit manager by an LPN, but the DON confirmed that no investigation or witness statements were collected. The facility's policy mandates thorough investigations for all allegations, observations, or suspected cases of abuse, neglect, misappropriation of property, exploitation, or injuries of unknown sources, which was not followed in these cases.
Failure to Update Care Plans for PTSD and Specialized Wheelchair
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to deficiencies in their care. Resident 66, who was admitted with a diagnosis of PTSD, did not have an updated care plan addressing this condition. Despite showing symptoms of depression and expressing feelings of tiredness and lack of interest in activities, the care plan for Resident 66 did not include any interventions related to PTSD. The Social Services Director was unaware of the PTSD diagnosis and had not written a care plan for it, indicating a lapse in communication and documentation within the facility's care planning process. Resident 55, who has Alzheimer's disease and dementia, was observed using a specialized wheelchair provided by hospice for four to six months. However, the care plan for Resident 55 was not updated to reflect the use of this specialized wheelchair. The Unit Manager confirmed that the care plan had not been revised to include this critical piece of equipment. This oversight in updating the care plan could lead to inappropriate care and services for Resident 55, who is dependent on staff for all activities of daily living and has severe cognitive impairment.
Failure to Provide Appropriate Care and Timely Medical Appointments
Penalty
Summary
The facility failed to ensure that two residents received care and treatment in accordance with professional standards of practice. Resident 55, who has Alzheimer's disease and is severely cognitively impaired, was observed in a specialized wheelchair without proper support. The headrest was angled away from her head, and her left leg was dangling without the support of a leg pedal. Staff interviews revealed that the headrest and leg pedal were not consistently utilized, and there was confusion about whose responsibility it was to ensure these supports were in place. The Rehabilitation Director confirmed that the headrest and leg pedal should be used at all times when the resident is in the wheelchair. Resident 67, who is cognitively intact and has a history of Guillain-Barre syndrome and pruritus, complained of excessive itching and believed she was being bitten by bugs. Despite her requests to see a dermatologist, no appointment was made. Observations and interviews revealed that the resident had reddened and scabbed areas on her skin, and her complaints were documented in the medical record. However, the Assistant Director of Nursing and the Social Service Director were unaware of her request for a dermatology appointment, and no orders for such an appointment were obtained. The facility's failure to provide appropriate support for Resident 55's head and leg while in the wheelchair and the delay in obtaining a dermatology appointment for Resident 67 highlight deficiencies in adhering to professional standards of care. These lapses were confirmed through observations, staff interviews, and record reviews, indicating a need for improved communication and adherence to care plans within the facility.
Failure to Provide Appropriate ROM Services
Penalty
Summary
The facility failed to ensure that a resident with a history of stroke and cerebral palsy received appropriate services to maintain or improve her range of motion (ROM). The resident, who was cognitively intact, had functional limitations in ROM on one side for both the upper and lower extremities. Despite this, the resident did not receive any restorative therapy or exercises to prevent a decline in her contractures. The only intervention documented was the placement of a washcloth in her contracted right hand, which was insufficient to address her needs. Interviews with the resident and staff revealed that the resident did not receive any exercises for her hand and foot, and there was no restorative program in place for her. The Assistant Director of Nursing (ADON) and the MDS Coordinator both confirmed that the resident had not been assessed for restorative exercises, and there was no designated nurse responsible for the restorative program. The facility's policy indicated that residents with potential for decline should be referred to the restorative nurse aid (RNA) program, but this was not done for the resident in question.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that a resident received respiratory care consistent with professional standards of practice. Specifically, the facility did not place the resident's nebulizer tubing and pipe into a covered bag to minimize the spread of pathogens. This deficiency was observed during a survey, where the nebulizer machine and its components were found on the bedside table without a barrier or bag. The resident, who had been admitted with diagnoses including heart failure and chronic obstructive pulmonary disease (COPD), was at risk for infection due to this oversight. The resident's medical records indicated a need for nebulizer treatments four times a day and the use of oxygen at night. Despite these requirements, the facility did not follow proper storage protocols for the respiratory equipment. An interview with an LPN confirmed that nebulizer masks and pipes should be bagged when not in use, but this was not done for the resident in question. The facility was unable to provide a policy for storing respiratory equipment when requested by the surveyors.
Failure to Complete AIMS Assessment and Properly Document PRN Psychotropic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (R78) who was administered antipsychotic medication, Abilify, for Alzheimer's disease, dementia, and major depressive disorder. The AIMS assessment was not performed upon initiating the medication but was delayed by 57 days. The facility's policy required AIMS assessments at admission, readmission, and quarterly if the resident has orders for psychotropic medication. The Unit Manager confirmed that the AIMS assessment was not done at the time the medication was started and could not provide an assessment for the previous quarter before the survey team exited. This failure placed the resident at risk for unrecognized side effects and a diminished quality of life. Additionally, the facility failed to have a stop date and diagnosis for the use of an as-needed (PRN) psychotropic medication, Lorazepam, for another resident (R59) who had a history of stroke and diabetes and was severely impaired in cognition. The Physician Order for Lorazepam was open-ended without a discontinue date and lacked a diagnosis for its use. The Licensed Practical Nurse (LPN) and Consultant Pharmacist were unaware of the need for an end date and proper diagnosis for the medication. The facility's policy required that each resident's drug regimen be free from unnecessary drugs, and PRN orders for psychotropic medications should be limited and necessary. This oversight placed the resident at risk for unrecognized side effects and a diminished quality of life.
Failure to Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure an insulin pen was removed from one medication cart after 28 days for one of 18 Kwik pens that were observed for open date and expiration date. During an observation with a Registered Nurse (RN), it was revealed that the Kwik pen for a resident had an open date that was smudged and not legible. The RN confirmed that the Kwik pen was expired and had been used to administer insulin to the resident when their blood sugar was 375. The Director of Nursing (DON) confirmed that the expectation was for expired insulin pens to be removed from the cart and not used. Review of the physician orders in the electronic medical record (EMR) indicated that the resident was to receive four units of Humalog Kwik Pen U-100 insulin if their blood sugar was greater than 300. The manufacturer's guidelines state that opened Humalog prefilled pens must be discarded 28 days after first use. The facility's policy on medication storage also mandates that no outdated or deteriorated drugs be retained for use. Despite these guidelines, the expired insulin pen was not removed, leading to the deficiency.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to ensure the reach-in refrigerator in the kitchen was properly maintained, which had the potential to affect 98 of the 99 residents who consume food from the kitchen. During a tour of the kitchen, it was observed that the refrigerator had a leak resulting in about an inch of water at the bottom, which was almost reaching the rim of a cookie sheet with condiments on it. Several boxes of Jello were visibly wet from the leak, and the water extended onto the floor when the doors were opened. The issue persisted the following day, with a thick slice of cheese wrapped in saran wrap observed submerged in the water. Dietary staff confirmed that the refrigerator had been leaking for at least six months, sometimes causing water to leak onto the floor. The maintenance staff, who had been employed since February 19, 2024, stated that logbooks were kept at each nursing station for items needing attention and were checked daily. However, the maintenance staff was only notified about the refrigerator leak on the day of the interview. The administrator, acting as the maintenance director, confirmed that they had been without a Maintenance Director for a few weeks and were only notified about the leak the previous day. A review of the Maintenance Repair Log revealed that the issue was noted on August 10, 2023, but there was no indication that it had been repaired. The dietary director mentioned that the state had visited in August 2023 and indicated that the refrigerator should be fixed, but it was left as a concern without a violation, leading to the repair notice being written in the log.
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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