Pinnacle Point Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, Missouri.
- Location
- 4700 Nw Cliffview Drive, Riverside, Missouri 64150
- CMS Provider Number
- 265379
- Inspections on file
- 27
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Pinnacle Point Wellness & Rehabilitation during CMS and state inspections, most recent first.
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.
The facility failed to accommodate the needs of a non-English speaking resident by not providing consistent communication aids, leaving the resident without engagement in their primary language. Additionally, another resident was not provided appropriate seating during meals, making self-feeding difficult. Staff were not adequately trained on using communication tools, and recommendations for alternative seating were not implemented.
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents at least two days before the end of their Medicare Part A stay. The NOMNC was issued and signed on the last day of coverage for both residents. Interviews revealed that the Business Office Manager and Administrator were unaware of the proper procedure and timeline for issuing the NOMNC, leading to non-compliance with CMS guidelines.
The facility failed to maintain acceptable noise levels and a clean, comfortable environment for its residents. A resident with cognitive loss was distressed by a continuously beeping door alarm, while another resident with anxiety and depression was disturbed by a loud clunking noise from a broken smoking cart wheel. The facility also had multiple unclean and damaged areas, with ineffective housekeeping and maintenance practices. The lack of a sound level policy and delayed corrective actions contributed to these deficiencies.
The facility failed to ensure residents were free from physical restraints, as evidenced by the improper use of a seat belt for a resident with severe cognitive impairment and locked wheelchair brakes for another resident with significant cognitive loss. The facility did not have necessary physician orders, assessments, or care plans for these restraints, leading to inappropriate restriction of residents' freedom of movement.
The facility did not conduct timely FCSR background checks for a Dietary Aide, an LPN, and a CNA before they interacted with residents, contrary to its Abuse Prevention Policy. The Human Resources Manager and Administrator acknowledged the oversight, which allowed these employees to have contact with residents without the required pre-screening.
The facility failed to complete accurate and timely MDS assessments for several residents. A resident was discharged without a discharge MDS, another had no MDS updates for months, a third passed away without a final MDS, and a fourth's MDS did not reflect dialysis treatment. Staff interviews revealed issues with obtaining RN signatures and unawareness of unsubmitted assessments.
The facility failed to develop comprehensive care plans for residents, neglecting to address critical areas such as BIPAP machine use, side rail usage, and significant weight loss. A resident's care plan did not include BIPAP use despite respiratory conditions, and side rails were used without documentation. Another resident's care plan lacked side rail documentation, despite their use for repositioning. Two residents experienced significant weight loss without care plan interventions. Staff interviews revealed a lack of awareness and updates in care plans.
Two residents in a facility, both dependent on staff for ADLs and always incontinent, did not receive necessary perineal care every two hours as required. Observations showed staff failed to reposition or assess the need for care over several hours, despite strong urine odors indicating neglect. Interviews with CNAs confirmed the lack of care, and care plans did not address routine incontinent care, leading to deficiencies in maintaining residents' personal hygiene.
The facility failed to address significant weight loss and provide adequate hydration for several residents. One resident experienced a 13.56% weight loss over six months without a care plan or interventions. Another resident lost 15.34% of their body weight over three months, with no specific interventions documented. Observations showed a lack of fluids and snacks, and inconsistent assistance during meals. Staff interviews revealed discrepancies in hydration procedures, contributing to these deficiencies.
The facility failed to assess bed rail entrapment risks for four residents, leading to the installation of side rails without proper evaluation or physician's orders. Residents had various medical conditions requiring careful consideration before using bed rails. The facility lacked a policy on entrapment, and entrapment evaluations were incomplete.
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate. Errors included improper blood sugar testing procedures for multiple residents, incorrect application and removal of pain patches, and delayed meal service after insulin administration. These deficiencies affected the care of several residents, highlighting issues in medication management and adherence to physician orders.
Two residents experienced issues with the palatability and attractiveness of their meals. One resident with severe cognitive impairment struggled with dry rice, while another with moderate cognitive impairment and a history of stroke was served disliked rice and dry chicken. The facility lacked a policy for resident food preferences, and the Dietary Manager was unaware of complaints.
The facility was found to have multiple maintenance issues, including dust, debris, and mold-like substances in various areas, chipped paint, and rusted frames. Interviews revealed unclear responsibilities between housekeeping and maintenance staff, and no written plan for repairs. The administrator expected the building to be clean and in good repair.
The facility failed to maintain an effective pest control program, leading to the presence of gnats, flies, and wasps in resident rooms, dining areas, and hallways. Observations revealed multiple instances of pests, including flies landing on a resident and crawling on their bed. The facility lacked a pest control policy, and pest control services were limited to outside fly control. The Administrator acknowledged the issue and stated that pest control would be notified.
A resident with dementia and anxiety was treated without dignity when a CNA shook their shirt despite requests to stop, and an LPN restricted their movement by yelling at them for self-propelling their wheelchair. The facility's actions disregarded the resident's rights to a dignified existence and self-determination.
A resident with bilateral sensorineural hearing loss did not receive assistance from the facility in obtaining a hearing aid. The care plan lacked documentation of the resident's hearing needs, and there was confusion among staff about responsibilities. The Social Services Director and transportation person did not document or follow up effectively, leading to delays in obtaining the hearing aid.
A significant medication error occurred when a resident did not receive a meal within the required time after receiving fast-acting insulin. The resident's blood sugar was checked, and 4 units of Humalog insulin were administered, but the meal was delayed by nearly an hour, contrary to the manufacturer's guidelines. The LPN assumed the resident had gone to the dining room, but the resident remained in their room and expressed hunger. The DON confirmed that the insulin should be given no earlier than 10 minutes before a meal.
The facility failed to complete performance reviews of CNAs at least once every 12 months and did not provide regular in-service education based on the outcome of the reviews. A review of 52 CNA personnel files revealed this deficiency, and the Executive Director admitted to not having the necessary competency evaluations.
The facility failed to ensure proper food safety and hygiene practices, including unsealed food in the freezer, dirty containers, dusty shelving, and a dietary cook not performing hand hygiene while handling food and equipment.
The facility failed to have a written transfer agreement with a hospital to ensure timely hospital admission and information exchange for residents. The Executive Director was unaware of the Federal requirement and believed it was not necessary in Missouri. She had never seen a written transfer agreement at the facility and stated she would begin the process of obtaining one.
The facility failed to implement and maintain their infection prevention and control program, resulting in a lack of documentation and tracking of infections. The Infection Preventionist, new to the position, acknowledged the deficiencies, and the Corporate Nurse confirmed the need for improvement towards compliance with IPCP regulations.
The facility failed to ensure residents who smoked were assessed and supervised according to their needs. Several residents were observed smoking unsupervised outside designated areas, and the facility did not have a system to identify and monitor residents' smoking needs. Additionally, care plans and smoking evaluation tools were incomplete or missing for some residents.
The facility failed to ensure timely administration and availability of prescribed medications for eight residents, resulting in a medication error rate of 49.15%. Issues included assumptions about resident refusals, delays in administration, and failure to reorder medications on time.
The facility failed to implement and maintain their IPCP program to monitor and evaluate antibiotic use for their 115 residents. The Infection Preventionist admitted to not having implemented the program and could not provide documentation for ongoing review. The Corporate Nurse confirmed awareness of the issue and stated the goal was to improve the program towards compliance.
The facility failed to notify the Ombudsman of two unplanned, facility-initiated hospital discharges for a resident with multiple medical conditions. The Social Services Director did not include the resident in the monthly discharge lists for November 2023 and March 2024, resulting in a lack of required notification.
The facility failed to ensure accurate completion of MDS assessments for two residents under PASARR and for one resident under the Antipsychotic Medication section. The inaccuracies were due to the MDS Coordinator completing assessments without always having access to the paper charts, leading to incorrect documentation of PASARR evaluations and antipsychotic medication use.
The facility failed to develop a comprehensive care plan for a resident with chronic wounds and edema, despite having orders for Lasix and Bumex. Staff interviews confirmed that the care plan should have been updated to include these conditions.
The facility failed to administer physician-ordered glaucoma eye drops as prescribed for a resident. The resident's MAR for April 2024 showed multiple instances of missing documentation, indicating that the medications may not have been given. The interim DON confirmed that the lack of documentation meant the facility could not prove the medications were administered.
A resident with chronic pain did not receive prescribed Hydrocodone for over a week due to the facility's failure to reorder the medication. Staff did not adequately assess the resident's pain or offer alternative pain management, and the Interim Director of Nursing was unaware of the issue until it was reported.
The facility failed to maintain a qualified administrator from mid-February to early March 2024. Administrator A, who had not yet obtained a license, assumed the role without being listed as a current Missouri Licensed Administrator. The application for a Temporary Emergency License was incomplete and delayed, resulting in a gap in qualified administrative oversight.
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.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide adequate accommodations for a non-English speaking resident, identified as Resident #104, who primarily spoke Spanish. Despite the resident's care plan indicating the use of a communication board and Google Translate for communication, observations revealed that these tools were not consistently utilized. The resident was often left without engagement or entertainment in their primary language, and staff frequently communicated with the resident in English, which the resident did not understand. Interviews with staff indicated a lack of awareness and training on using communication aids, and the resident's family had to frequently assist with communication and care. Additionally, the facility did not provide appropriate seating accommodations for another resident, identified as Resident #26, during meal times. This resident, who had significant cognitive loss and was dependent on a wheelchair, was observed sitting at a dining table that was too high, causing difficulty in self-feeding. The resident's wheelchair was not appropriately fitted, leading to challenges in reaching the table and resulting in the resident eating with their fingers. Despite recommendations from the therapy department for alternative seating arrangements, such as using an over-bed table, these were not implemented. The facility's failure to accommodate these residents' needs and preferences highlights a lack of adherence to the residents' rights to dignified existence and communication. The absence of a policy on accommodating residents' needs further exacerbated the issue, as staff were not adequately trained or informed on how to effectively communicate and provide care for residents with language barriers or specific physical needs.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 to Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay. This deficiency affected two residents, as evidenced by the review of their medical records. Resident #1's record indicated that the NOMNC was issued and signed on the same day that Medicare Part A benefits were ending, failing to meet the required two-day notice period. Similarly, Resident #93's record showed the NOMNC was also issued and signed on the last day of coverage, not adhering to the mandated timeline. Interviews conducted with the Business Office Manager and the Administrator revealed a lack of awareness and understanding regarding the proper procedure for issuing the NOMNC. The Business Office Manager was unaware that the residents did not receive the notice within the required timeframe, while the Administrator could not recall the specific time frame for issuing the NOMNC and was unsure who was responsible for providing the form to residents. This lack of knowledge and procedural oversight contributed to the facility's failure to comply with the CMS guidelines for notifying residents about the end of their Medicare coverage.
Facility Fails to Maintain Acceptable Noise Levels and Clean Environment
Penalty
Summary
The facility failed to maintain acceptable noise levels and a clean, comfortable environment for its residents, as observed in the cases of two residents. Resident #35, who has significant cognitive loss and uses a wheelchair, was observed in distress due to a continuously beeping door alarm in the Special Care Unit dining room. The alarm was caused by a propped-open patio door, and the resident was seen covering their ear and displaying a distressed expression. Additionally, Resident #77, who has intact cognitive skills but suffers from anxiety and depression, reported being disturbed by a loud clunking noise from a broken smoking cart wheel, which had been an issue for over a month and affected their sleep. The facility also failed to maintain a sanitary and orderly environment, as evidenced by multiple observations of unclean and damaged areas throughout the facility. These included stained carpets, dusty light fixtures, chipped paint, and mold-like substances in air conditioning units. The facility's housekeeping and maintenance policies were not effectively implemented, as indicated by the presence of debris, unpainted drywall patches, and broken equipment. Interviews with staff revealed a lack of communication and follow-up on maintenance issues, contributing to the ongoing deficiencies. Furthermore, the facility did not have a policy on sound levels, which may have contributed to the noise-related issues experienced by the residents. The maintenance director acknowledged awareness of some of the problems, such as the broken smoking cart wheel, but corrective actions were delayed. The Director of Nursing expressed expectations for a clean and comfortable environment, yet the facility's practices did not align with these expectations, resulting in a failure to uphold residents' rights to a safe and homelike environment.
Improper Use of Restraints in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the improper use of a seat belt for one resident and locked wheelchair brakes for another. Resident #11, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed with a seat belt fastened across their lap, which they could not release independently. The facility did not have a physician's order, assessment, or care plan for the use of the seat belt, and staff were unaware of the resident's ability to release it. Interviews with staff and administration confirmed that the seat belt should not have been in use without proper evaluation and documentation. Resident #84, who has significant cognitive loss and uses a wheelchair for mobility, was observed with locked wheelchair brakes, preventing them from moving freely. The resident expressed distress and discomfort, indicating they did not want the brakes locked. Staff interviews revealed that the brakes were locked to keep the resident in place, despite the understanding that locked brakes constitute a restraint if the resident cannot unlock them independently. The resident's care plan did not address the use of locked wheelchair brakes, and staff acknowledged that the brakes should not have been locked without the resident's ability to release them. The facility's failure to obtain necessary physician orders, conduct assessments, and update care plans for the use of restraints resulted in the improper use of a seat belt and locked wheelchair brakes for these residents. The facility's policies and the Missouri Resident Rights emphasize the right of residents to be free from restraints, yet these incidents demonstrate a lack of adherence to these guidelines, leading to the inappropriate restriction of residents' freedom of movement.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its Abuse Prevention Policy by not conducting timely background checks through the Family Care Safety Registry (FCSR) for three employees before they had contact with residents. The policy, dated October 2022, mandates pre-screening of potential employees for a history of abusive behavior. However, the personnel files of a Dietary Aide, an LPN, and a CNA revealed that their FCSR checks were conducted after their hire dates, allowing them to interact with residents without the necessary background screening. Interviews with the Human Resources Manager and the Administrator confirmed that the FCSR checks should have been completed before any employee had contact with residents, highlighting a lapse in the facility's hiring process.
Inaccurate and Untimely MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately and timely for four residents. Resident #72 was discharged to another long-term care facility, but no discharge MDS was completed or submitted. Resident #84 had an admission MDS completed, but no subsequent MDS assessments were completed or submitted for several months. Resident #33 had an admission and a Prospective Payment System (PPS) MDS completed, but no MDS assessments were completed or submitted in the months leading up to their death, and no discharge assessment was completed post-mortem. Resident #39's quarterly MDS failed to reflect their dialysis treatment, despite physician orders and care plans indicating the necessity of dialysis. Interviews with facility staff revealed systemic issues contributing to these deficiencies. The MDS Coordinator acknowledged difficulties in obtaining Registered Nurse signatures, leading to delayed MDS submissions. The Coordinator was unaware of any unsubmitted discharge MDS assessments and could not explain the lack of a current MDS for Resident #84. The Director of Nursing and the Administrator both expressed expectations for timely and accurate MDS submissions, yet these expectations were not met, resulting in incomplete and inaccurate resident assessments.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing critical care areas. For Resident #39, the care plan did not include the use of a bilevel positive airway pressure (BIPAP) machine, despite the resident's respiratory conditions and the resident's expressed desire for its use at night. Additionally, the care plan did not address the use of side rails, which the resident used for repositioning in bed. Observations and interviews revealed that the BIPAP machine was not consistently applied, and the side rails were not documented in the care plan, despite being used by the resident. Resident #113's care plan also lacked documentation regarding the use of side rails, which were present on the resident's bed. The resident had involuntary movements and used the side rails to assist with repositioning, yet this was not reflected in the care plan. Staff interviews indicated a lack of awareness about the reason for the side rails, and the side rail evaluation did not support their use, highlighting a disconnect between the resident's needs and the care plan. For Residents #26 and #84, the facility failed to address significant weight loss in their care plans. Both residents experienced substantial weight loss over several months, yet their care plans did not include interventions to address or mitigate this issue. The MDS coordinator and the Director of Nursing acknowledged the expectation for care plans to include such interventions, but the care plans remained incomplete, indicating a failure to update and implement necessary care strategies for these residents.
Failure to Provide Timely Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services for dependent residents who were unable to perform activities of daily living, specifically in providing perineal care at least every two hours. This deficiency affected two residents, both of whom were always incontinent of bowel and bladder and dependent on staff for all ADLs. Observations showed that staff did not reposition or assess the need for incontinent care for these residents over several hours, despite the facility's policy requiring routine perineal care after each incontinent episode. Resident #11, with severe cognitive impairment and diagnoses including cerebral palsy and quadriplegia, was observed lying in bed without being repositioned or provided incontinent care for over three hours. Interviews with CNAs revealed that they had not provided the necessary care since arriving at work, acknowledging that the resident should be repositioned and provided care every two hours. The resident's care plan did not address incontinence or incontinent care, contributing to the oversight. Similarly, Resident #19, with moderate cognitive impairment and diagnoses including Guillain-Barre syndrome, was observed in a room with a strong smell of urine, indicating a lack of timely incontinent care. Staff interviews confirmed that the resident had not been repositioned or provided perineal care since the start of their shift. The care plan for this resident also failed to address routine incontinent care, leading to the deficiency in maintaining the resident's personal hygiene.
Inadequate Hydration and Weight Loss Management
Penalty
Summary
The facility failed to adequately address significant weight loss and provide sufficient hydration for several residents. Resident #26 experienced a 13.56% weight loss over six months, with no care plan or interventions documented to address this issue. Observations revealed that the resident was not consistently provided with fluids or assistance during meals, contributing to inadequate hydration and nutrition. Despite a physician's order for an appetite stimulant, there was no evidence of consistent follow-up or notification of the physician regarding the resident's weight loss. Resident #84 also suffered from significant weight loss, losing 15.34% of their body weight over three months. The resident's care plan did not include specific interventions to address this weight loss, and observations showed a lack of fluids and snacks available to the resident. Staff did not consistently assist the resident during meals, and there was no documentation of efforts to encourage or monitor the resident's food and fluid intake. Additional residents, including #35, #57, and #4, were observed to have inadequate hydration, with inconsistent documentation of fluid intake and a lack of fluids available at bedside. Staff interviews revealed a lack of consistent procedures for providing fluids and snacks, with discrepancies in the reported times and frequency of hydration cart rounds. The facility's failure to adhere to its hydration policy and lack of individualized care plans for weight loss and hydration contributed to these deficiencies.
Failure to Assess Bed Rail Entrapment Risks
Penalty
Summary
The facility staff failed to properly assess residents for the risk of entrapment from bed rails before their installation. This deficiency was observed in four out of 21 sampled residents. The facility did not have a policy on entrapment, and there were no physician's orders for the use of side rails for these residents. The residents involved had various medical conditions, including cognitive impairments, mobility issues, and other health diagnoses, which necessitated careful consideration before the use of bed rails. For Resident #39, the facility did not complete a full entrapment assessment, and the bed's dimensions were not appropriately measured against FDA recommendations. Despite the resident's request for side rails to assist with repositioning, there was no documented physician's order for their use. Similarly, Resident #113 had side rails installed without a proper assessment or physician's order, and the entrapment evaluation was incomplete. The resident's involuntary movements were noted, but the side rail committee had recommended against their use. Resident #54 also had side rails installed without a physician's order, and the entrapment evaluation was not fully documented. The resident used the side rails for mobility assistance, but this was not care planned. Lastly, Resident #104 had side rails without a completed side rail evaluation form or physician's order. The entrapment evaluation was incomplete, and staff were unsure of the necessity of the side rails. The facility's maintenance director was tasked with completing entrapment evaluations, but there was a lack of clarity and consistency in the process.
Medication Administration Errors and Delays in Insulin Management
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 20% error rate. This was observed through various incidents involving five residents. For instance, Resident #4, who has diabetes mellitus and chronic obstructive pulmonary disease, had their blood sugar checked without allowing the alcohol wipe to air dry, contrary to proper procedure. Similarly, Resident #15's blood sugar was checked after only a four-second air dry, and Resident #43's blood sugar was checked after a six-second air dry, both of which were insufficient according to the facility's standards. Resident #91 experienced issues with the application and removal of Salonpas patches. The patches were not removed at the scheduled time, and the MAR inaccurately indicated that they had been removed. This oversight was confirmed when the nurse found the patches still on the resident the following morning, despite documentation stating otherwise. The resident reported shoulder pain and expressed that the patches were supposed to be removed at night. Resident #103, who requires insulin for diabetes management, did not receive their meal within the recommended time frame after insulin administration. The resident's blood sugar was checked, and insulin was administered according to the sliding scale, but the meal was delayed by approximately an hour. This delay was contrary to the manufacturer's guidelines for Humalog insulin, which should be administered no earlier than 10 minutes before a meal. The LPN involved assumed the resident had gone to the dining room, leading to the oversight.
Failure to Provide Palatable and Attractive Food
Penalty
Summary
The facility failed to provide food that was palatable and attractive, affecting two residents. Resident #85, who had severe cognitive impairment and required assistance with eating, was observed struggling with dry rice that was served in the form of an ice cream scoop. The resident expressed that the food was very dry. The care plan for Resident #85 indicated the need to obtain and update food preferences and serve the diet as ordered, but there was no policy provided for resident food preferences. Resident #52, with moderate cognitive impairment and a history of stroke and dementia, was observed having difficulty eating dry chicken and was served rice despite disliking it. The meal ticket indicated a preference against rice, yet it was still served. The Dietary Manager was unaware of any current food complaints, and the Administrator expected food to be served palatably. The facility census was 103, and the deficient practice was noted during observations and interviews.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain the physical environment in good repair, as observed in various areas including the Special Care Unit, dining/activity room, nurse's station, and entrance areas. Specific issues included dead bugs, dust, and debris in light fixtures, scratched and chipped paint on doors, scuffed and stained floor tiles, and black mold-like substance on PTAC units. Additionally, there were cobwebs, rusted and chipped window frames, and cracked tiles in several locations. These deficiencies were noted to potentially affect all residents, with a census of 103. Interviews with housekeeping and maintenance staff revealed a lack of clarity and coordination in responsibilities for cleaning and repairs. Housekeeping staff indicated that maintenance was responsible for high dusting and cleaning lights, while the maintenance director stated that housekeeping should handle these tasks. The maintenance director also acknowledged awareness of rusted door frames and the need for patching and painting but noted that no contractor had been contacted for repairs. Furthermore, there was no written plan for the repair and upkeep of the building, and the administrator expressed an expectation for the building to be clean and in good repair.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, flies, and wasps in various areas, including resident rooms, dining rooms, and hallways. Observations on multiple occasions revealed gnats in a specific room, flies in the dining room, and both flies and gnats in another room, where a fly strip with dead flies was also noted. A resident reported frequent fly infestations in their room, with flies landing on them and crawling on their bed. Additionally, wasps were observed on the wall of the Special Care Unit's nursery room, and another room had multiple flies crawling on a resident and their bed. The facility did not provide a pest control policy, and the review of pest service invoices indicated that the pest control program was limited to outside fly control services conducted monthly from July to September. During an interview, the Administrator acknowledged the existence of a pest control program but noted that fly strips should not be present in resident rooms and stated that pest control would be notified of the concerns.
Resident Dignity and Respect Deficiency
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the actions of staff towards a resident with significant cognitive impairment. The resident, who had a diagnosis of dementia and anxiety, was observed sitting in the hallway when a Certified Nurse Aide (CNA) grabbed and shook the resident's shirt despite the resident's repeated requests to stop. The CNA continued this behavior, dismissing the resident's protests as playful interaction. This incident was witnessed by surveyors and highlighted a lack of respect for the resident's right to a dignified existence. Additionally, the resident was subjected to disrespectful treatment by a Licensed Practical Nurse (LPN) who yelled at the resident for self-propelling their wheelchair in the hallway. The LPN repeatedly called the resident back to the nurses' station, restricting their movement within the secured care unit. The resident expressed dissatisfaction with being confined to certain areas, indicating a disregard for their right to self-determination. Interviews with the Director of Nursing and the Administrator confirmed that such actions were inappropriate and not aligned with the facility's expectations for resident care.
Failure to Assist Resident in Obtaining Hearing Aid
Penalty
Summary
The facility failed to assist a resident, identified as Resident #82, in obtaining a hearing aid, despite the resident's diagnosis of bilateral sensorineural hearing loss. The resident's care plan did not address the hearing issues or the need for a hearing aid, and there was a lack of documentation regarding the process of obtaining the hearing aid. The resident had undergone a hearing test at a local hospital but had not received the hearing aid, and there was no communication with Social Services about the issue. Interviews with facility staff revealed a lack of clarity and responsibility in the process of obtaining the hearing aid. The Social Services Director indicated that the transportation person was responsible for scheduling appointments and following up, but did not document any information in the resident's chart. The transportation person confirmed they were waiting for Medicaid approval and did not have access to charting, while the Director of Nursing stated that Social Services should document the process. The Administrator expected the Social Services Director to play a larger role in obtaining the hearing aid, rather than leaving it to transportation.
Significant Medication Error Due to Delayed Meal After Insulin Administration
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving a resident who did not receive a meal within the required time after receiving fast-acting insulin. The facility's policy for medication administration requires that medications be administered as prescribed and in accordance with professional standards. However, the policy did not specify the time frame for providing a meal after administering insulin. The manufacturer's guidelines for Humalog insulin indicate that it should be administered 15 minutes before a meal. In this case, the resident's blood sugar was checked, and 4 units of Humalog insulin were administered at 11:54 A.M. The resident did not receive a meal until 12:52 P.M., nearly an hour after the insulin was given, contrary to the manufacturer's guidelines. Observations showed that the resident remained in their room without being checked on by staff after receiving insulin. The LPN responsible for administering the insulin assumed the resident had gone to the dining room to eat. However, the resident stayed in their room and expressed hunger at 12:42 P.M. The Director of Nursing confirmed that the physician's orders should be followed and that Humalog should be given no earlier than 10 minutes before a meal. The delay in providing the meal after insulin administration was identified as a significant medication error, as the resident should not have waited 45 minutes to an hour to eat after receiving fast-acting insulin.
Failure to Complete CNA Performance Reviews and Provide In-Service Education
Penalty
Summary
The facility failed to complete a performance review of nurse aides at least once every 12 months and did not provide regular in-service education based on the outcome of the review. This deficiency was identified through interviews, record reviews, and a review of the facility's policy. The facility's policy, dated 07/01/03, mandates that all new employees, including CNAs, must undergo orientation within the first 40 hours of employment and complete specific training topics annually. However, a review of 52 CNA personnel files revealed that the facility did not adhere to this policy, as no performance reviews or competency evaluations were completed for the CNAs within the required 12-month period. During an interview, the Executive Director admitted that she did not have the CNAs' competency evaluations and could not provide the necessary documentation. This lack of adherence to the facility's policy and federal regulations resulted in the facility failing to ensure that CNAs received the required performance reviews and in-service education, which are critical for maintaining the quality of care provided to residents.
Failure to Ensure Proper Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, which had the potential to affect all residents consuming food from the kitchen. During an observation, it was noted that the freezer contained an open bag of hamburgers, eight plastic containers ready for use were dirty with dried food particles, and two metal shelving units with dust collected on them. Additionally, during a tray line observation, a dietary cook handled food and equipment without performing hand hygiene. The cook unplugged a hot box with bare hands, transported it through hallways, and continued to serve food after picking up utensils and a pen from the floor without washing hands. Interviews with the dietary cook and the dietary manager revealed a lack of awareness and adherence to proper hand hygiene and sanitization practices. The dietary manager acknowledged the need to stay within regulations and maintain a clean kitchen, while the administrator emphasized the importance of sanitizing and washing hands when processing and handling food. These observations and interviews indicate a failure to follow the facility's policy on sanitizing equipment and food contact surfaces, posing a risk to the health and safety of the residents.
Lack of Written Transfer Agreement with Hospital
Penalty
Summary
The facility failed to ensure a written transfer agreement with a hospital was in effect to assure residents of timely hospital admission when medically appropriate and necessary information would be exchanged between providers. On 04/18/24, the written transfer agreement(s) with the community hospital(s) was requested from the Executive Director, but no written transfer agreement was provided. During an interview on 04/19/24, the Executive Director stated that the facility did not have a written transfer agreement, believing it was not a requirement in Missouri and that the community understood residents would be treated at the hospital without one. The Executive Director was unaware of the Federal requirement for a written transfer agreement and had never seen one at the facility since she had been working there for a few months. She stated she would immediately begin the process of obtaining a written transfer agreement with the community hospital.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain their established infection prevention and control program (IPCP) for surveillance, tracking, trending, and administration of corrective actions to prevent and control the spread of identified infections. The facility's policy for IPCP included completing a monthly infection control surveillance log with detailed information about each infection case, such as the resident's identifying information, infection onset date, diagnostic test outcomes, infection site, culture results, and resolution date. However, this surveillance action was not implemented, leading to a lack of documentation and tracking of infections within the facility, which had a census of 115 residents. During an interview, the Infection Preventionist (IP) stated she had completed her certification process recently and had been in the position for one month. She was unaware of the previous IP or if the facility had employed one in the past several months. The IP acknowledged the lack of documentation for tracking and trending infections and was trying to improve the process. The Corporate Nurse also confirmed awareness of the documentation deficiencies and stated that the goal was to improve the program towards compliance with IPCP regulations, policies, and procedures.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to ensure residents who smoked were assessed and that supervision was provided in accordance with their assessed needs. Residents were observed smoking unsupervised outside of designated areas. The facility did not have a system in place to individually identify and determine if residents needed staff to maintain their smoking materials, care plan such needs, and implement a monitoring system for five of 22 residents who smoked. Additionally, the facility failed to develop a care plan for one of the residents who smoked. One resident, R11, was readmitted with diagnoses including chronic obstructive pulmonary disease and had a BIMS score indicating moderate cognitive impairment. The resident's care plan did not reflect that they were a smoker, and the smoking evaluation tool was incomplete. Another resident, R81, who was cognitively intact, was observed smoking outside the designated area without supervision. The smoking evaluation tool for R81 was also incomplete, and the resident admitted to obtaining cigarettes and a lighter from another person in the facility. Other residents, including R17, R5, and R87, were also observed smoking without proper supervision and outside designated areas. R17, who was cognitively intact, kept smoking materials in their scooter basket and expressed dissatisfaction with the lack of supervision. R5, who had a traumatic brain injury and was cognitively intact, kept cigarettes in a lockbox in their room and smoked outside the building unsupervised. R87, who had chronic obstructive pulmonary disease and moderate cognitive impairment, was observed smoking and admitted to having access to cigarettes despite the facility's policy. The facility's staff admitted to forgetting to document necessary information in the smoking evaluation tools, and the Executive Director confirmed that residents should be supervised while smoking in designated areas.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure prescribed medications were administered at the prescribed time and were available for administration for eight of 13 residents. This resulted in 29 medication errors out of 59 opportunities, leading to a medication error rate of 49.15%. The facility's policy mandates that medications be administered in accordance with written orders of attending physicians and within a specific time frame, which was not adhered to in these cases. For instance, one resident did not receive a prescribed patch because the LPN assumed the resident would refuse it, while another resident received their medication late due to the LPN's delay. Additionally, a resident did not receive their pain medication because it was not available in the facility, and the LPN failed to reorder it in a timely manner. Another resident did not receive their insulin as scheduled because the LPN was unable to administer it on time. Other residents also experienced delays in receiving their medications, including those for diabetes, pain management, and other chronic conditions. The interim director of nursing confirmed that medications should be given at the time ordered by the physician and acknowledged the lapses in timely administration. These failures highlight significant issues in medication management and adherence to physician orders within the facility.
Failure to Implement and Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and maintain their infection prevention and control (IPCP) program critical element to monitor and evaluate antibiotic use and to track measures of usage in the facility for their entire population of residents, which had a census of 115. The facility's policy on the Antibiotic Stewardship Program, updated on 10/01/22, outlined guidelines for monitoring antibiotic use, including collecting reports on antibiotic susceptibility patterns, reviewing the appropriateness of antibiotic administration, establishing standards for clinical monitoring of adverse drug events from antibiotic use, and using microbiology culture data to guide future antibiotic selection. During an interview, the Infection Preventionist (IP) acknowledged familiarity with the IPCP standards and goals but admitted to not having implemented them yet and could not provide documentation for the facility's ongoing review of antibiotic stewardship. The Corporate Nurse also confirmed awareness of the lack of documentation and stated that the goal was to improve the program towards compliance with IPCP regulations, policies, and procedures.
Failure to Notify Ombudsman of Unplanned Hospital Discharges
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of two unplanned, facility-initiated hospital discharges for a resident. The resident, who had diagnoses including spinal stenosis, osteomyelitis, and a right leg below-the-knee amputation, experienced an unplanned discharge to the hospital on two separate occasions. The first discharge occurred on 11/09/23 due to an urgent medical need related to a wound infection, and the second discharge occurred on 03/27/24 due to a non-healing wound on the left foot with drainage and odor. In both instances, the Ombudsman was not notified of the discharges as required. The Social Services Director (SSD) typically provided a monthly report of all discharges to the Ombudsman but failed to include the resident in question on the discharge lists for November 2023 and March 2024. The SSD acknowledged that the resident did not appear on the discharge list for those months and admitted that an extra step was needed to ensure hospitalizations were included. The failure to notify the Ombudsman was confirmed during staff interviews and a review of the facility's records.
Inaccurate MDS Assessments for PASARR and Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessment under the Pre-Admission Screening and Resident Review (PASARR) for two residents and under the Antipsychotic Medication section for one resident. Resident 7 was admitted with diagnoses including schizophrenia and anxiety disorder. Despite having a PASARR Level II evaluation indicating a serious mental illness and requiring a structured environment and medication management, the MDS assessment inaccurately documented that the resident had not been evaluated by PASARR Level II. Additionally, the MDS assessment inaccurately documented that the resident had not received antipsychotic medications, despite records showing a prescription for olanzapine for schizophrenia. The MDS Coordinator admitted to completing the MDS without always having access to the paper chart, leading to these inaccuracies. Resident 41 was admitted with diagnoses including intellectual disabilities, schizophrenia, and major depressive disorder. The PASARR Level II Evaluation Report indicated a serious mental illness but no intellectual disability requiring specialized mental health services. However, the MDS assessment inaccurately documented that the resident had not been evaluated by PASARR Level II. The MDS Coordinator also admitted to not being aware of the PASARR Level II evaluation for this resident and completing the MDS without always having access to the paper chart, resulting in the inaccurate documentation.
Failure to Develop Comprehensive Care Plan for Chronic Wounds and Edema
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan to address a resident's chronic wounds and edema. The resident, who was admitted with diagnoses including edema and stroke affecting the right side of the body, had orders for Lasix and Bumex to manage edema. Despite these orders and the resident's ongoing treatment for chronic wounds and edema, the care plan did not include any specific measures for these conditions. This oversight was confirmed through a review of the resident's electronic medical record and interviews with staff members. During interviews, the Administrator acknowledged that care plans should be updated based on information gathered in morning meetings. The Minimum Data Set Registered Nurse (MDSRN) also confirmed that the chronic edema and wound care should have been included in the care plan and expressed uncertainty about how this was missed. The resident was not interviewable, and the facility census at the time was 115.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer physician-ordered glaucoma eye drops as prescribed for one resident (R44) out of a sample of 29 residents. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had specific orders for timolol, latanoprost, Trusopt, and Brimonidine eye drops to be administered at various times throughout the day. However, a review of the resident's Medication Administration Record (MAR) for April 2024 revealed multiple instances where the administration of these medications was not documented, indicating that the medications may not have been given as prescribed. During an interview, the interim director of nursing confirmed that the absence of documentation in the MAR boxes under the specified dates meant that the facility could not prove the medications were administered. This failure to document and potentially administer the prescribed medications constitutes a deficiency in meeting professional standards of quality care for the resident.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that pain medication (Hydrocodone) was available for a resident (R24) who required it. R24, who was admitted with diagnoses including polyneuropathy, diabetes mellitus, rheumatoid arthritis, pain, and a history of right femur fracture, had a physician's order for Hydrocodone-Acetaminophen 5-325 mg to be administered twice a day. However, from 04/11/24 to 04/19/24, the medication was not available, and the resident did not receive the prescribed pain management. During this period, the resident reported moderate pain levels and expressed frustration over the lack of effective pain relief, despite repeatedly asking staff about the medication's availability. The staff failed to assess the resident's pain adequately or offer alternative pain management solutions during this time. Additionally, the resident's Medication Administration Record (MAR) indicated that the pain medication was not administered as ordered, and the pain scale was documented as zero for each shift, which contradicted the resident's reported pain levels. Interviews with staff revealed a lack of knowledge and training on reordering medications, and the Interim Director of Nursing (IDON) was unaware of the issue until it was brought to their attention. The IDON stated that emergency pharmacies could have been used to obtain the medication promptly, but this option was not utilized. The facility's failure to ensure the availability of prescribed pain medication and to provide appropriate pain management for R24 resulted in the resident experiencing unmanaged pain for an extended period.
Failure to Maintain Qualified Administrator
Penalty
Summary
The facility failed to maintain a qualified administrator on duty from February 15, 2024, to March 3, 2024, as required by state laws. Administrator B informed the state survey agency on February 14, 2024, that they were no longer the Administrator of record. Subsequently, Administrator A, who had completed the Administrator in Training program but had not yet taken the test to obtain an administrator license, assumed the role. However, Administrator A was not listed as a current Missouri Licensed Administrator, and there was uncertainty about whether anyone at the corporate level was a licensed administrator in Missouri to act in the interim. The application process for Administrator A's Temporary Emergency License (TEL) was mishandled. A partial application was submitted on February 15, 2024, but it lacked the full licensure application, application fee, and required records such as a birth certificate and proof of high school graduation. Despite follow-up emails from the Missouri Board of Nursing Home Administrators (MBNHA) on February 20 and February 26, 2024, the necessary documents were not promptly provided. The full application and fee were only received on February 27, 2024, but still lacked some required documents. Consequently, a TEL was not issued to Administrator A until March 4, 2024.
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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