Rehab Of Kansas City South
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 8033 Holmes, Kansas City, Missouri 64131
- CMS Provider Number
- 265758
- Inspections on file
- 37
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rehab Of Kansas City South during CMS and state inspections, most recent first.
A cognitively intact resident with paraplegia, cognitive communication deficit, and major depressive disorder received a 30‑day involuntary discharge notice for non‑payment that contained an incorrect discharge date and lacked complete receiving‑facility information. The facility proceeded with discharge planning despite a care plan entry indicating the resident opted to stay and despite the resident’s expressed desire to remain where they had friends. After the resident’s family notified the facility and the Ombudsman by email that they were appealing the discharge, the facility did not review the appeal email until after the resident had been transported by facility van to another facility and did not allow the resident to return while the appeal was pending, contrary to policy and appeal protections.
Persistent and strong odors of feces and urine were present throughout a hallway, as reported by a family member and confirmed by staff and direct observation. The Housekeeping Supervisor attributed the odors to a resident's medical condition and stated that cleaning and deodorizing would occur if odors were noticed. The strong odor was acknowledged by a Regional RN Consultant.
A resident with significant impairments had a $300 charge from their CashApp account traced to a nurse, but the allegation was not promptly investigated or reported. Multiple mandated reporters, including the Social Worker, HR, and BOM, were aware of the incident but deferred action to the interim Administrator, who did not initiate an investigation or notify authorities as required by facility policy.
Multiple spa room toilets were found unbolted and easily movable, with some spa rooms inaccessible or blocked by equipment. A resident with hemiplegia and hemiparesis was unable to use their own inoperable toilet and reported feeling unsteady and fearful when using the unsecured spa toilets. Staff were unaware of these issues prior to surveyor observation, and maintenance had not received related work orders.
Two separate incidents occurred in which residents with behavioral and mental health diagnoses engaged in physical altercations, resulting in one resident being punched in the face and another being pushed to the ground and injured. Staff were present but did not prevent the escalation to physical abuse, and required behavioral monitoring was not in place for one resident prior to the incident.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or infections, as observed by the absence of EBP signage and PPE in hallways and rooms. Staff lacked awareness of EBP protocols, performing care without necessary PPE. Documentation did not consistently reflect EBP needs, and protocols were only implemented after the survey began.
The facility failed to ensure complete and accurate documentation for residents requiring dialysis, as required by their Dialysis Care policy. Several residents' records lacked comprehensive communication tools, and assessments of dialysis access sites were inconsistently documented. Interviews revealed that staff struggled to obtain complete documentation from the dialysis provider, and there was inadequate follow-up on missing information, potentially impacting resident care.
The facility did not post complete daily nurse staffing information, omitting the total hours worked for RNs, LPNs, and CNAs. The Staffing Coordinator used an incorrect form, and neither the Administrator nor the DON verified the postings, leading to non-compliance with the facility's policy.
A facility failed to ensure proper medication storage and administration, with medications left unattended at residents' bedsides and unlocked medication carts. The medication room was unclean, and refrigerator temperatures were not consistently monitored. Staff interviews revealed non-compliance with facility policies.
A facility failed to provide written notification to a resident and their family before transferring the resident to a hospital. The resident, who was moderately cognitively impaired, experienced a change in condition, prompting a transfer to the emergency room. Interviews revealed that staff did not adhere to the facility's policy requiring advance written notice of transfers.
The facility failed to properly store respiratory equipment and obtain necessary physician orders for two residents. One resident's nebulizer was not stored in a plastic bag, and there was no physician's order for its use, despite receiving medication. Another resident used a BiPAP machine without a documented order, and the mask was found uncovered. Staff interviews revealed a lack of awareness and adherence to facility policies regarding equipment storage and documentation.
Three residents who were dependent on staff for bathing and hygiene did not have their preferences for shower frequency accommodated, with some going up to two weeks without a shower and expressing feelings of uncleanliness. Care plans lacked documentation of individual preferences, and staff interviews revealed that showers were not always provided according to a set schedule, with decisions sometimes based on staff observation or staffing limitations rather than resident choice.
A resident with significant mobility impairments was not fully secured in a motorized wheelchair during van transport, as only three straps were used instead of the required four. During a turn, the wheelchair tipped, causing the resident to hit their head on the window. Staff interviews revealed confusion about proper securing procedures and a lack of verification by the driver, leading to the incident.
The facility failed to ensure a safe and homelike environment when multiple leaks occurred, affecting two residents. Additionally, the facility did not maintain clean floors in the rooms of three residents. The facility's policies and communication were inadequate, contributing to the residents' discomfort and the unsafe environment.
Improper Involuntary Discharge and Failure to Honor Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate and lawful discharge and to honor an appeal of an involuntary transfer for one resident. The facility’s transfer and discharge policy, dated June 2020, required that residents be transferred or discharged only for specific reasons, that a 30‑day written notice be provided with the effective date, receiving facility information, and appeal rights, and that residents not be transferred or discharged while an appeal was pending. For this resident, a 30‑Day Notice of Involuntary Discharge dated 1/15/26 cited failure to pay as the reason and listed allowable outstanding charges of $17,809.40, but the form did not include the current facility name and, when later emailed to the Ombudsman, did not include the address of the receiving facility. The notice also contained an incorrect discharge date (2/7/26 instead of 2/17/26), and the facility proceeded with discharge planning based on this notice. The resident had a history of paraplegia, cognitive communication deficit, and major depressive disorder, and was assessed as cognitively intact on the quarterly MDS dated 1/14/26. The Administrator reported that the resident’s family member, who held DPOA that was not enacted, initially agreed via text on 1/15/26 to the transfer and asked where the resident would be moved, and the Administrator identified the new facility. The Administrator stated that a care plan meeting scheduled for 1/15/26 was canceled by the family with the resident’s agreement, and that at first the resident wanted to leave. The day before the scheduled transfer, the resident reported that the family member told them not to leave, but the next morning the resident reportedly said they were okay with the transfer and asked that the family member meet them at the new facility. The resident’s care plan, updated 2/9/26, documented that the resident opted to stay at the facility, indicating a preference to remain. On the day of transfer, the resident was placed in a wheelchair, taken onto the facility van with belongings, paperwork, and medications, and transported to the new facility. The Administrator stated that when the family member arrived and stopped the van, the resident made no indication they wanted to get off and proceeded to the new facility, although the resident later reported that they were taken to the new facility and that they wanted to go back to the original facility where they had friends. The Ombudsman reported that the family member notified their office of an appeal and that on 2/11/26 the facility’s SSD emailed the 30‑day discharge notice, which lacked the address of the receiving facility. The Ombudsman stated that an appeal hearing was scheduled for 4/2/26 and that the resident should have been allowed to return to the facility during the appeal process. The Administrator acknowledged that an email from the family member notifying the facility of the appeal was sent on 2/11/26 at 3:35 P.M., but it was not read until after the resident had already left on 2/12/26, and the resident was not allowed to return during the pending appeal.
Failure to Prevent and Address Pervasive Odors in Resident Hallway
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents on the 300 Hall, as evidenced by persistent and pervasive odors of feces and urine. A family member reported experiencing strong body odor smells during multiple visits over a three-month period, describing the facility as unclean and the odors as overwhelming to the point of being unable to visit their family member. The Housekeeping Supervisor attributed the odors to residents' medical conditions and stated that housekeeping would clean and deodorize areas if odors were detected, with additional deodorizers available if needed. Direct observations confirmed a strong odor around a specific resident room and extending throughout the hallway, which was also acknowledged by the Regional Registered Nurse Consultant.
Failure to Timely Investigate and Report Alleged Misappropriation of Resident Funds
Penalty
Summary
An allegation of possible misappropriation of a resident's funds was not investigated in a timely manner after a family member reported a $300 charge from the resident's CashApp account, which was traced back to a nurse in the facility. The resident involved had diagnoses including legal blindness, muscle weakness, and cognitive communication deficit. The family discovered the unrecognized transaction after retrieving and charging the resident's phone, and requested that the facility involve law enforcement. Multiple staff members, including the Social Worker, Human Resources, and Business Office Manager, acknowledged awareness of the allegation and recognized it as a reportable incident. However, none of these mandated reporters took action to report the incident, each deferring responsibility to the interim Administrator, who was filling in during the Administrator's medical leave. The interim Administrator did not initiate an investigation, did not document attempts to contact the family, and did not report the allegation to the Department of Health and Senior Services or law enforcement, citing a lack of further information from the family. The facility's Abuse and Prohibition Program policy requires immediate reporting and investigation of suspected misappropriation of resident property, with specific timeframes for notifying authorities. Despite these requirements, the incident was not reported or investigated as mandated, and documentation of the facility's response was lacking. The deficiency centers on the failure to follow established protocols for timely investigation and reporting of alleged misappropriation of resident funds.
Unsecured and Inaccessible Spa Room Toilets Affect Resident Safety
Penalty
Summary
The facility failed to maintain several spa room toilets in a safe and operable condition, as observed and confirmed through interviews and record reviews. Specifically, the toilets in the 100 and 300 Hall Spa Rooms were not securely bolted in place and could be moved easily, while the 200 Hall Spa Room toilet was inaccessible due to being blocked by stored equipment. The 400 Hall Spa Room was also inaccessible, and the toilet in one resident's room was inoperable for a period of time. These deficiencies were directly observed during facility rounds and confirmed by staff interviews, with staff expressing surprise and concern upon discovering the unsecured toilets. A resident with hemiplegia and hemiparesis following a stroke was unable to use their own bathroom due to the inoperable toilet and reported feeling unsteady and fearful when attempting to use the unsecured spa room toilets. The resident also noted that other toilets in the facility were not bolted down. Staff interviews revealed a lack of awareness regarding the unsecured toilets and the blocked or inaccessible spa rooms, and maintenance staff had not received prior reports or work orders related to these issues, except for the clogged toilet. The facility census at the time was 89 residents, and the issues potentially affected all residents utilizing the spa bathroom toilets.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, resulting in two separate altercations involving four residents. In the first incident, two residents with significant physical and mental health diagnoses, including bilateral leg amputations, schizophrenia, anxiety disorder, and traumatic brain injury, were involved in a physical altercation on the back patio. Video footage showed one resident attempting to enter the building while the other was blocking the doorway, leading to a verbal exchange, physical contact, and ultimately one resident punching the other in the face. Staff were present and intervened after the physical abuse occurred. In the second incident, two cognitively intact residents with histories of schizophrenia, schizoaffective disorder, anxiety disorder, major depressive disorder, and PTSD were involved in an altercation in the dining room. The altercation began as a verbal dispute over money, escalating when one resident allegedly pushed the other to the ground. The resident who fell sustained injuries to the nose and left knee. Staff entered the dining room after the incident and separated the residents. It was noted that behavioral monitoring, which should have been in place for one of the residents, was not implemented prior to the incident. Both incidents were confirmed by staff interviews and facility investigation summaries as physical abuse. The facility's policies defined abuse and outlined staff responsibilities for intervention and redirection of residents exhibiting behavioral symptoms. However, in both cases, staff failed to prevent the escalation of resident-to-resident altercations, resulting in physical harm.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or infections. Observations revealed that there were no signs indicating EBP on the doors of residents who required such precautions, nor were there isolation carts with personal protective equipment (PPE) available in the hallways or resident rooms. This deficiency was noted for residents undergoing dialysis and a resident with a feeding tube, among others. Interviews with staff, including CNAs, LPNs, and the Infection Preventionist, indicated a lack of awareness and understanding of EBP protocols. Staff members were observed performing care activities without wearing the necessary PPE, such as gowns, despite the presence of residents with conditions that warranted EBP. The staff's lack of knowledge was further highlighted by their inability to recall recent training on EBP or the specific PPE required for different care activities. The facility's documentation, including care plans and physician orders, did not consistently reflect the need for EBP for residents with conditions like dialysis shunts, PICC lines, or open wounds. The Infection Preventionist admitted that EBP protocols and signage were only implemented after the survey began, indicating a reactive rather than proactive approach to infection control. This oversight in infection prevention measures posed a risk of transmission of resistant organisms within the facility.
Incomplete Dialysis Documentation and Communication
Penalty
Summary
The facility failed to ensure complete and accurate documentation related to dialysis care for several residents. The facility's Dialysis Care policy required comprehensive communication and documentation between the facility and the dialysis provider, including pre- and post-dialysis vital signs, weights, and any issues encountered during dialysis. However, for multiple residents, the Dialysis and Nursing Home Handoff Communication Tools were either incomplete or missing entirely. For instance, one resident's records showed only partial documentation of weights and vital signs, and there was no follow-up by facility staff to retrieve missing information from the dialysis provider. Additionally, the facility did not consistently document assessments of residents' dialysis access sites, as required by their care plans and physician orders. For some residents, the Nurses' Administration Records showed inconsistent or incorrect documentation codes, and there was no evidence that the facility staff followed up on missing or incomplete documentation. Interviews with staff, including the Director of Nursing (DON) and Licensed Practical Nurses (LPNs), revealed that the facility struggled to obtain complete documentation from the dialysis provider and that staff did not always ensure that the necessary information was recorded in the residents' medical records. The facility's failure to maintain accurate and complete documentation of dialysis care and communication with the dialysis provider was further compounded by inadequate follow-up on missing information. The DON acknowledged that the facility had ongoing issues with receiving complete documentation from the dialysis provider and that staff were not consistently documenting assessments of dialysis access sites in a standardized manner. This lack of documentation and follow-up could potentially impact the quality of care provided to residents requiring dialysis.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the facility name, daily census, and actual hours worked per shift for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) responsible for resident care. Observations on multiple dates revealed that the posted staffing sheets did not display the total number of hours worked for RNs, LPNs, or CNAs. The facility's Nurse Staffing Posting Policy, revised in June 2020, required this information to be posted daily at the beginning of each shift in a clear and readable format accessible to residents and visitors. Interviews with the Staffing Coordinator, Administrator, and Director of Nursing (DON) revealed a lack of awareness and understanding of the requirements for posting staffing information. The Staffing Coordinator admitted to using a form that did not include a space for actual hours worked and was unaware of the need to include total hours worked per job title. The Administrator and DON both acknowledged that they did not verify the accuracy of the posted staffing information and were unaware that the facility was using an incorrect form that lacked the required details.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and handling of medications, as evidenced by several observations and interviews. Medications were left unattended at the bedside for three residents, despite the absence of physician orders permitting such practice. This was observed in the cases of a resident who was not present in their room, with pills found on the bedside tray and under the bed, and another resident who reported that staff routinely left medications at their bedside. Additionally, medication carts were found unlocked and unattended in the hallway, posing a risk of unauthorized access by residents. The medication storage areas, including carts and the medication room, were not maintained in a clean and organized manner. Loose pills were found in the drawers of medication carts, along with personal items such as hair clips and car fobs. The medication room was also found to be lacking in cleanliness, with a dirty sink and no paper towels available for handwashing. Furthermore, the medication refrigerator's temperature was not consistently monitored, with records showing temperatures below the recommended range, potentially compromising the integrity of stored medications. Interviews with staff, including LPNs, CMTs, and the DON, revealed a lack of adherence to the facility's policies regarding medication storage and administration. Staff acknowledged that medication carts should be locked when not in use and that medications should not be left at the bedside without a physician's order. The responsibility for monitoring refrigerator temperatures and ensuring cleanliness in medication storage areas was not consistently upheld, leading to the observed deficiencies.
Failure to Provide Written Notification Before Resident Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their family prior to the resident's transfer to a hospital. The deficiency involved a resident who was moderately cognitively impaired according to their Minimum Data Set (MDS) assessment. On the day of the incident, the resident exhibited a change in condition, including leaning to one side, facial drooping, and an elevated pulse rate. The physician was notified, and an order was given to send the resident to the emergency room for evaluation and treatment. However, there was no documentation of written notification to the resident or their family regarding the transfer. Interviews with facility staff revealed a lack of adherence to the facility's Transfer and Discharge policy, which requires reasonable advance notice of transfer or discharge. The social worker and an LPN both indicated that they did not provide written notices to residents or their families when a transfer occurred. The Director of Nursing stated that the responsibility for providing written notification lay with the licensed nurse on duty at the time of transfer, but there was no evidence that this procedure was followed. This oversight resulted in the failure to inform the resident and their family in writing about the transfer to the hospital.
Deficiency in Respiratory Equipment Management
Penalty
Summary
The facility failed to ensure proper storage and physician orders for respiratory equipment for two residents. Resident #55, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Obstructive Sleep Apnea, had a nebulizer mouthpiece that was repeatedly observed not stored in a plastic bag as required by facility policy. Additionally, there was no physician's order for the nebulizer treatment, despite the resident receiving medication for it. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the absence of a physician's order and acknowledged the responsibility of nursing staff to maintain the equipment in a sanitary condition. Resident #57, with diagnoses including abnormalities of breathing and heart failure, was using a BiPAP machine without a documented physician's order. The BiPAP mask was found uncovered in the resident's dresser drawer, contrary to the facility's policy that requires such equipment to be stored in a plastic bag when not in use. Interviews with various staff members, including a Certified Nursing Assistant (CNA), Certified Medication Technician (CMT), and the MDS nurse, revealed a lack of awareness regarding the resident's use of a BiPAP machine and the absence of corresponding orders in the care plan. The facility's failure to adhere to its policies regarding respiratory equipment storage and physician orders was evident in both cases. The Assistant Director of Nursing (ADON) and other staff members acknowledged the oversight in maintaining equipment cleanliness and ensuring proper documentation. The DON admitted to not being aware of the missing orders for Resident #57's BiPAP machine, highlighting a breakdown in communication and documentation processes within the facility.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing and showering preferences of three sampled residents, all of whom were dependent on staff for personal hygiene due to significant physical or cognitive impairments. The facility's policy required that residents' individual needs and preferences be accommodated unless health or safety would be endangered, but care plans and documentation did not consistently reflect or address residents' stated preferences for shower frequency or timing. For example, one cognitively intact resident reported going up to two weeks without a shower and expressed a desire for more frequent showers, especially around holidays and when expecting visitors. Another resident, also cognitively intact, stated a preference for daily showers but was only receiving them once every two weeks at times, and reported feeling unclean and that this affected their mood. A third resident, who was severely cognitively impaired, also indicated a desire for more frequent showers than were being provided. Observations and interviews revealed that residents sometimes had visible signs of uncleanliness, such as crumbs and stains on clothing or body odor. Staff interviews indicated that showers were not always provided according to a set schedule, and that decisions about when to shower residents were sometimes made based on staff observation rather than resident preference or a documented schedule. Documentation of shower refusals was incomplete, with no reasons recorded for refusals, and staff acknowledged that showers were sometimes missed due to staffing issues or because the shower aide was assigned to other duties. The care plans reviewed did not consistently document residents' specific bathing or showering preferences, and there was a lack of clear scheduling or communication regarding when showers would be provided. Residents reported not being offered showers as frequently as they desired, and staff confirmed that the established shower schedule was not always followed. The facility census at the time was 91 residents, and the deficiency was identified through observation, interview, and record review.
Resident Not Properly Secured During Van Transport
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, bilateral upper and lower extremity impairments, and a left knee contracture was not properly secured during transport in the facility van. The facility's Safe Transportation Unloading Procedure required that wheelchairs be locked and secured with tie-down hooks, and that four straps be used to secure each wheelchair. On the day of the incident, the resident was transported in a motorized wheelchair along with another resident. The transportation escort attached only three straps to the resident's wheelchair, and the driver did not verify that all four straps were used or properly secured. During the trip, the resident's wheelchair tipped over when the van turned a corner, causing the resident to hit their head on the window. The wheelchair was found leaning against the other resident's wheelchair, and the left-side straps were not attached to the van floor. Interviews revealed that the transportation escort was not fully aware of the protocol, believing that two to four straps could be used, and had previously experienced a strap coming loose from the van floor with another resident. The driver acknowledged responsibility for ensuring all wheelchairs were properly secured but failed to double-check the straps before transport. The maintenance director, who supervised the driver, stated that drivers were trained to use four straps but had not provided education to the escort. The facility's records did not indicate any new interventions or plans to prevent recurrence following the incident. The resident involved was cognitively intact and dependent on staff for all transfers and mobility, using a motorized wheelchair. After the incident, the resident reported head pain and sought hospital evaluation. The lack of adherence to the facility's transportation safety procedures and insufficient staff training and oversight directly led to the resident not being fully secured, resulting in the accident during van transport.
Facility Fails to Ensure Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe and homelike environment when multiple leaks occurred, affecting two residents. Resident #3, who has diagnoses including osteomyelitis, diabetes, and COPD, reported the leak around 5:00 A.M. after it worsened. The facility's response was limited to placing towels and a bucket under the leak, causing Resident #3 to feel upset and unsafe. Resident #2, who has pneumonia and unspecified psychosis, also experienced discomfort due to the leak, which started around 3:00 A.M. and worsened by 7:30 A.M. Despite informing the staff, the resident's bed remained wet, and the facility did not take adequate measures to address the issue promptly. Additionally, the facility failed to maintain clean floors in the rooms of three residents. Resident #10's room had a buildup of brown grime and debris, and Resident #6's room had debris and red stains on the floor. Resident #4's room had a heavy buildup of debris between the bed and the wall. The housekeeping staff did not adequately clean these areas, and the Housekeeping Supervisor acknowledged noticing similar issues in the past but did not ensure proper cleaning. The facility's policies and communication were also inadequate. The Rapid Response Guide: Flood did not specifically address water leaks in resident rooms. Staff members, including the DON and the Maintenance Director, were not promptly informed about the leaks. The Administrator and DON were only made aware of the situation through a group text and did not take immediate action to relocate the affected residents or address the leaks effectively. This lack of timely communication and action contributed to the residents' discomfort and the unsafe environment.
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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