Seneca Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Seneca, Missouri.
- Location
- 914 Chickesaw Street, Seneca, Missouri 64865
- CMS Provider Number
- 265491
- Inspections on file
- 20
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Seneca Nursing during CMS and state inspections, most recent first.
Staff failed to consistently document administration of controlled pain medications on both the MAR and the controlled substance records for three residents receiving opioid analgesics for chronic and PRN pain. Facility policy required special recordkeeping for DEA-controlled drugs and stated that current accountability records be maintained in the MAR or designated book. Record review showed numerous instances where hydrocodone-acetaminophen and oxycodone doses were signed out on the narcotic sheets without matching entries on the MAR, and in some cases, doses were documented on the MAR without corresponding narcotic sheet entries. Nursing staff and CMTs reported that they were expected to document on both records and that the two should match, while the administrator described the problem as a documentation issue.
Failure to Honor Resident Shower Preferences: The facility did not honor shower preferences for three residents with significant care needs, including dementia, COPD, a catheter, and severe cognitive impairment. Shower records showed limited bathing, while progress notes did not document showers or refusals. One resident reported feeling dirty and wanting showers twice weekly, another appeared with oily hair and body odor, and a responsible party reported an unshaved resident with long toenails, poor oral care, and soiled clothing. The DON and Administrator said residents should be kept clean and preferences should be honored, but were unaware the residents were not receiving showers twice per week.
Failure to protect residents from resident-to-resident abuse occurred when a resident with severe cognitive impairment and repeated boundary-crossing behaviors touched, kissed, bit, and attempted to lie on or undress around other residents. Multiple residents reported unwanted breast and chest touching, one reported the resident naked on top of him/her and pulling at a central line, and another reported an attempted bite near a pacemaker area. Staff interviews showed they recognized such conduct as abuse, but several incidents were not documented in progress notes and reporting was inconsistent.
Failure to Report Resident-to-Resident Abuse Allegations: Staff did not immediately report multiple abuse allegations involving unwanted touching, kissing, and other inappropriate resident-to-resident contact to management and DHSS within the required 2-hour timeframe. The incidents involved a resident with intellectual disabilities, deafness, and hemiplegia, another resident with dementia and CKD, and additional residents who reported being touched, bitten, or awakened to unwanted sexual contact; records showed the events were documented inconsistently or not at all, and DHSS self-reports were not made.
Failure to Investigate Resident-to-Resident Abuse Allegations: The facility did not document timely or thorough investigations, or steps to protect residents, after multiple allegations of unwanted touching and sexualized behavior between residents. A resident with intellectual disabilities and communication limitations was repeatedly involved in inappropriate conduct with other residents, while another resident with dementia was observed fondling the resident’s breasts. Other residents reported being touched, bitten at, and sexually approached, but the record lacked documented investigation and protective actions.
A resident with multiple chronic conditions, including DM, CHF, HTN, and CKD, had admission labs ordered, and subsequent CBC results showed critically low Hgb and Hct values. Although facility policy required immediate practitioner notification and documentation of abnormal lab values, there was no record that the physician or family were notified, and later MD notes and dietician entries indicated no labs were available or reviewed. The Medical Director confirmed she had not been informed of the critical results and that the signature on the lab report was not hers, while leadership and nursing staff acknowledged that nurses were responsible for monitoring labs, receiving critical values from the lab, notifying the physician via the message system or phone, and documenting this communication, which did not occur in this case.
A resident with multiple chronic conditions and identified fall risk slid from a recliner to the floor without injury, but staff failed to document the incident itself in the medical record, despite facility policies requiring charting of all significant condition changes and falls. An LPN entered a fall follow-up note based on shift report, yet no primary note describing the event was present. An RN later acknowledged witnessing the resident slowly slide from the chair to the floor and admitted this should have been documented. The DON and Administrator both stated that sliding from a chair is considered a fall and must be recorded, but the absence of documentation left the resident’s record incomplete and inaccurate.
A facility failed to provide appropriate respiratory care for a resident with COPD and respiratory failure. Staff did not clarify hospital discharge orders for pulse oximetry, leading to a lack of documentation and monitoring of oxygen usage and pulse oximetry readings. The resident's TAR did not include necessary orders, and staff did not consistently document oxygen saturations, despite expectations for spot checks.
A facility failed to maintain complete medical records for a resident who died, as staff did not document the death or notifications to the physician and family. The resident, with chronic conditions, was found without a pulse, and although the RN informed the physician and family, these actions were not recorded. Interviews confirmed the expectation for documentation, which was not met, violating the facility's policy.
The facility failed to ensure six NAs completed CNA training and obtained certification within four months of employment. NAs were observed working without certification, and interviews revealed no current training classes. The facility lacked a policy for CNA certification, contributing to the deficiency.
The facility failed to maintain an effective infection control program, as staff did not perform proper hand hygiene during personal care for two residents and lacked a policy for Enhanced Barrier Precautions (EBP). A resident with a wound did not have appropriate EBP signage, and staff did not consistently use gowns when providing care. Interviews revealed inconsistent understanding and implementation of EBP among staff.
Controlled substances, including Ativan Intensol and morphine sulfate, were found in an unlocked refrigerator in the medication room, contrary to the facility's policy requiring double-lock storage. Staff interviews revealed awareness of the locking requirement, but lapses occurred, leading to the deficiency.
A facility failed to report a verbal abuse allegation to the state within the required timeframe. During a smoke break, a resident threatened another resident, which was documented by an RN but not reported to the DHSS. The resident who made the threat has a history of behavioral issues, while the threatened resident has moderate cognitive impairment. Staff interviews indicated awareness of reporting requirements, but the Administrator was unaware of the incident.
The facility failed to investigate a verbal abuse allegation where a resident threatened another resident, saying, 'I will cut your throat.' Despite the facility's policy requiring immediate reporting and investigation of abuse, no documented investigation was conducted. The resident who made the threat has a history of behavioral issues, and staff interviews confirmed the incident was considered abusive. However, the administrator was unaware of the incident, and the required investigation was not completed.
A facility failed to monitor and manage a resident's edema, notify the physician of significant changes, and apply prescribed interventions. The resident, with multiple diagnoses, was not consistently wearing Tubi grips as ordered, and staff did not document physician notification of weight gain and changes in edema. Observations showed significant edema and possible cellulitis, with inconsistent application of interventions.
Two residents experienced unsafe transfers due to staff not adhering to care plans. One resident, with dementia and muscle weakness, was transferred without a gait belt, contrary to their care plan. Another resident, with hemiplegia and hemiparesis, was transferred using a gait belt despite not bearing weight, which was not specified in their care plan. Staff interviews revealed a lack of adherence to facility policies regarding safe transfers.
The facility failed to maintain proper hand hygiene during meal service, as staff were observed handling food and food contact surfaces with bare hands without sanitizing between tasks. This was contrary to the facility's hand hygiene policy and FDA guidelines, potentially leading to contamination.
A resident's alprazolam medication went missing after being signed for by an LPN, who failed to properly count and log the medication. The facility's investigation revealed that the medication was not delivered to the resident, and staff had to use the emergency kit to provide the medication. Despite efforts to locate the missing doses, the facility could not account for them, indicating a lapse in medication management procedures.
A CNA in a LTC facility failed to treat a resident with dignity and respect by placing their hand near the resident's mouth to muffle yelling during care. The resident, who had severe cognitive impairment, was known to yell during care. The CNA claimed the action was accidental, but the facility's investigation confirmed the resident was not treated appropriately. Staff interviews emphasized the importance of treating residents with dignity.
A resident's cell phone was misappropriated by a staff member, who gave it as a gift to another staff member's child. The resident, with moderate cognitive impairment, had their phone reported missing, and it was later confirmed to belong to the resident by the cellular provider. The involved staff member was terminated, and the incident was reported to authorities.
Inconsistent Documentation of Controlled Pain Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and consistent documentation of the administration of controlled pain medications on both the Medication Administration Record (MAR) and the Controlled Substance Record for multiple residents. Facility policy dated 06/01/18 required that medications classified as controlled substances be subject to special handling, storage, disposal, and recordkeeping, and that current controlled substance accountability records be kept in the MAR or designated book. The policy also stated that the medication regimens of residents with discrepancies should be reviewed to assure residents received all medications ordered and that therapeutic goals were met. Despite this, surveyors identified numerous instances where documentation on the MAR did not match the Controlled Substance Record for three residents receiving opioid analgesics. For one resident with chronic back and leg pain related to diabetic neuropathy, cervical disc degeneration, gout, and restless legs syndrome, the physician ordered hydrocodone-acetaminophen both as a scheduled and PRN medication. Review of this resident’s records showed repeated mismatches between the Controlled Substance Record and the MAR. On multiple dates in January and February, staff documented administration of hydrocodone-acetaminophen on the Controlled Substance Record without corresponding entries on the MAR, and on other occasions documented administration on the MAR without corresponding entries on the Controlled Substance Record. Some entries on the Controlled Substance Record included notes that the resident was out of the building, yet the MAR did not reflect administration at those times. There were also instances where times were missing or unreadable on the Controlled Substance Record while the MAR showed administration, further demonstrating inconsistent documentation. A second resident with major depressive disorder, difficulty in walking, and muscle weakness had an order for PRN oxycodone 5 mg for moderate to severe pain. For this resident, the Controlled Substance Record repeatedly showed documented administrations of oxycodone on numerous dates across January, February, and March, while the MAR lacked corresponding entries for those same administrations. Each listed date and time on the Controlled Substance Record had no matching documentation on the MAR, indicating a pattern of incomplete or absent MAR documentation despite recorded use of the controlled medication. A third resident with cognitive communication deficit, muscle weakness, chronic kidney disease, and a care plan requiring routine pain management for lower back pain had an order for PRN hydrocodone-acetaminophen. For this resident, the Controlled Substance Record documented multiple administrations of hydrocodone-acetaminophen on various dates in February and March, but the MAR did not show corresponding entries for those administrations. On each of the cited dates and times, staff signed out the narcotic on the Controlled Substance Record, yet there was no MAR documentation to match. During interviews, certified medication technicians and registered nurses stated that staff were expected to document pain medications on both the MAR and the controlled drug form, and that the two records should match. The administrator also stated she expected staff to document on the MAR and narcotic sheet and acknowledged that failure to sign the MAR made it easy to forget, characterizing the issue as a documentation problem.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination when it did not honor reasonable shower preferences for three residents. The report states the facility did not provide a policy related to showers, and staff did not document shower refusals or provide nursing progress note entries related to showers provided or refused for the residents reviewed. The Director of Nursing and Administrator both stated that residents should be kept clean, that resident shower preferences should be honored, and that staff should document refusals, but they were unaware that the three residents were not receiving showers twice per week in March and April 2026. Resident #6 was admitted with diagnoses including infection and inflammatory reaction due to an internal left knee prosthesis, COPD, dementia, and uninhibited neuropathic bladder. The resident’s MDS indicated cognitive intactness, wheelchair use, an indwelling catheter, and supervision or touching assistance for showering and other ADLs. Shower sheets showed showers on only a few dates in March and April 2026, and the care plan had a cancelled intervention stating the resident was totally dependent on staff to provide a bath per schedule and as necessary, with no current bathing information. During interview, the resident said he/she preferred showers at least twice per week, felt dirty because of the catheter and bowel incontinence, and was unsure when the last shower occurred. Resident #7 had severe cognitive impairment and required supervision or touching assistance for showering, while Resident #8 had severe cognitive impairment, used a walker and wheelchair, and required substantial to maximal assistance for showering and toileting hygiene. Their care plans called for staff assistance with bathing, including sponge baths when full showers could not be tolerated, but shower sheets showed only limited showers in March and April 2026 and no documentation of refusals. During observation and interview, Resident #7 appeared with oily hair and mild body odor and stated a preference for showers twice per week. The responsible party for Resident #8 reported the resident had been unshaved, had long toenails, was not having teeth brushed, and had been found in soiled clothing, and expected showers at least twice per week and clean clothing daily.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse when one resident with intellectual disabilities, deafness, non-speaking status, hemiplegia, and severe cognitive impairment repeatedly engaged in inappropriate behaviors toward other residents. The resident’s care plan documented behaviors such as touching the breast area, pulling at clothing, lifting a shirt, and needing redirection away from other residents, but the record also showed repeated incidents in which the resident wandered into other residents’ rooms, removed clothing in common areas, lay against a male resident, and continued to ignore boundaries despite staff redirection. The record and resident interviews showed that multiple residents experienced unwanted contact. One resident reported being fondled on the breasts by another resident, while facility documentation later reflected disagreement among staff about whether the touching had actually occurred. Another resident stated that the resident in question entered the room unclothed, lay on top of him/her, touched the upper chest area, and pulled at a central line, prompting the resident to request a room change. A third resident reported that the resident tried to bite around a pacemaker area and attempted to touch the left chest, causing discomfort and anger. A fourth resident also reported that the resident tried to sit on his/her lap, and staff observed the resident sitting on a male peer’s lap in the common area. Facility documentation showed that several of these events were not documented in the residents’ progress notes, including the allegations of inappropriate touching, the room change request, and the biting/touching incident. Staff interviews reflected that they understood unwanted touching and sexual contact between residents to be abuse and that such behaviors should be documented and reported, yet the record showed inconsistent reporting and documentation. The DON stated that multiple residents had reported kissing and breast touching involving two residents, and that the Administrator believed the residents were exaggerating and not telling the truth before an investigation was initiated.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to report multiple allegations of abuse immediately to facility management and to DHSS within the required two-hour timeframe. The deficiency involved four residents and included incidents of unwanted touching, sexual contact, and other resident-to-resident behaviors that staff documented or that were reported by residents, but were not reported to the state as required. The facility policy stated that resident abuse must be reported immediately to the Administrator and that allegations involving abuse or serious bodily injury must be reported no later than two hours after the allegation is made. Resident #1, who had intellectual disabilities, was deaf, non-speaking, and had left-sided hemiplegia, was involved in several incidents. Nursing notes documented that the resident was found removing clothing in a common area with other residents present, was repeatedly redirected for inappropriate touching of his/her body, was found laying against a male resident and returning to the back area to lay on a couch with males present, and was found in another resident’s room going through belongings and trying to get into the resident’s bed. The record showed nursing and management were notified in some instances, but there was no documentation that these allegations were reported to DHSS, and DHSS records showed no self-report for those events. Resident #2, who had CKD, dementia with anxiety, and mild cognitive impairment, was documented as fondling Resident #1’s breasts. Staff redirected the resident and removed Resident #1 from the area, but the record did not document notification of family, physician, DON, Administrator, or DHSS, and DHSS records showed no self-report. Resident #3, who had acute osteomyelitis, PVD, and COPD, reported that while rooming with Resident #1, he/she woke up to Resident #1 naked on top of him/her, touching his/her upper chest and pulling at his/her central line; the resident also reported witnessing Resident #1 and Resident #2 kissing in the dining room. Resident #4, who had hemiplegia/hemiparesis following cerebral infarction, a pacemaker, and dysarthria, reported that Resident #1 tried to bite him/her near the pacemaker and touched his/her left chest. These resident reports were not documented in the progress notes, and DHSS records showed the facility did not self-report the allegations.
Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to complete timely and thorough investigations of allegations of resident-to-resident abuse and failed to document steps taken to protect residents while investigations were underway. The facility policy stated that residents have the right to be free from abuse, that the Administrator will ensure a thorough investigation of alleged violations of individual rights, and that steps will be taken to prevent further abuse during an investigation. Survey review found no documented timely investigation or protective measures for multiple allegations involving residents. Resident #1, who had intellectual disabilities, was deaf, non-speaking, and had hemiplegia, was documented on several occasions engaging in inappropriate or sexualized behaviors with other residents, including disrobing in common areas, repeated inappropriate touching, lying against a male resident, entering another resident’s room and trying to get into the resident’s bed, and sitting on a male peer’s lap. The record showed no documentation of a timely or thorough investigation, and no documentation of steps taken to protect others related to the incidents on 04/14/26, 04/20/24, 04/21/26, and 04/22/26. Resident #2, who had CKD, dementia with anxiety, and mild cognitive impairment, was observed fondling Resident #1’s breasts, and staff removed Resident #1 from the area. Resident #3 reported that Resident #1 was naked, laying on top of him/her, touching his/her upper chest, and pulling at his/her central line, and also reported seeing Resident #1 and Resident #2 kissing in the dining room. Resident #4 reported that Resident #1 tried to bite around the area of a pacemaker and tried to touch the resident’s left chest. For these allegations, the facility had no documentation of a timely investigation or steps taken to protect other residents during an investigation.
Failure to Notify Physician of Critical Lab Results and Document Communication
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of critical laboratory results and to document such notification, as required by facility policy. The facility’s Significant Condition Change and Notification policy required licensed nurses to immediately contact the medical practitioner for emergencies, including abnormal lab values, and to document each attempt to notify the practitioner and the resident’s representative. The Charting and Documentation policy further required staff to document the date and time specimens were obtained and the date and time the physician was notified of lab results. Despite these policies, the medical record for one resident contained no documentation that the physician or family were notified of critical lab findings. The resident was admitted with multiple significant diagnoses, including type 2 diabetes mellitus, heart failure, essential HTN, hypokalemia, hyperlipidemia, and chronic kidney disease stage 3. Admission orders included a CBC, CMP, TSH, BNP, and valproic acid level. A lab report collected several days after admission showed critically low hemoglobin of 5.1 g/dL and hematocrit of 18.7%, both flagged in the critical range. The lab report bore an illegible signature on the final page without a date, and there was no documentation in the resident’s chart that the physician or family had been notified of these critical results, nor any indication in subsequent physician notes that the labs had been reviewed. Over the following months, multiple progress notes by the dietician documented that no labs were located in the electronic medical record, and physician notes on several visits showed no documentation of lab review. Eventually, nursing notes documented that the resident was acting outside baseline with low blood pressure, and the family requested transfer to the hospital, where emergency department labs again showed severely abnormal hemoglobin and hematocrit values. Interviews with RN staff, the Medical Director, the DON, and the Administrator confirmed that nurses were responsible for monitoring lab results, that the lab should call the facility with critical values, and that staff were expected to notify the physician and document this notification. The Medical Director stated she had not been informed of the critical results, the signature on the lab report was not hers, and there was no record of staff notification, confirming that the facility failed to follow its own policies for critical lab result communication and documentation.
Failure to Document Resident Sliding/Fall Event in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records when staff did not document an incident in which a resident slid from a recliner to the floor. Facility policies on Significant Condition Change and Notification and on Charting and Documentation required that all significant changes, including falls, be recorded in the resident record, with charting each shift for 72 hours as needed, and that all pertinent changes in condition be documented concisely, accurately, and completely. Resident #1, admitted with diagnoses including Type 2 diabetes mellitus, heart failure, HTN, hypokalemia, hyperlipidemia, and stage 3 chronic kidney disease, had a care plan identifying potential for falls due to weakness and medication side effects. The resident’s quarterly MDS indicated intact cognition, substantial/maximal assistance needs for toileting, showering, and personal hygiene, and no falls. On the date in question, an LPN documented a fall follow-up note stating the resident had no latent injuries from an earlier fall and that staff should continue to monitor, based on information received in shift report. However, there was no documentation in the medical record of the actual fall or incident itself. An RN later reported that while working that day, the resident did not “fall” but slid slowly out of a recliner onto the floor, did not hit the head, and had no injury, and acknowledged that this sliding event should have been documented. The DON and the Administrator both stated they considered sliding out of a chair to be a fall and expected staff to document such events in the progress notes and, per the DON, to notify the responsible party. Despite these expectations and policies, the resident’s record lacked documentation of the sliding/fall event, resulting in an incomplete and inaccurate medical record.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for a resident with chronic obstructive pulmonary disease (COPD) and respiratory failure. The staff did not clarify the hospital discharge orders for pulse oximetry, which included instructions for a non-monitored home continuous pulse oximeter for spot checks. The discharge orders specified that if the resident's pulse oximeter reading fell below 90%, the hospital or emergency services should be contacted immediately. However, the facility did not document an order regarding pulse oximeter monitoring or directions for when to notify the physician. The resident's Treatment Administration Record (TAR) did not include the physician's order for oxygen at two liters via nasal cannula PRN for shortness of breath, nor did it include monitoring for pulse oximeter readings. Interviews with staff revealed that the resident had a pulse oximeter at their bedside and checked their own oxygen saturations, but staff did not consistently document these readings. The staff assumed spot checks meant checking the resident's oxygen saturations each shift, but this was not clarified with the physician, and the checks were not documented on the TAR. The Director of Nursing and other staff members acknowledged that the hospital discharge order should have been clarified with the physician, and that the facility did not perform continuous pulse oximetry checks. The Director of Nursing expected staff to perform spot checks at least three times a day to ensure the resident's oxygen saturations were at 95% and to notify the physician if they were below this level. However, this expectation was not communicated or documented, leading to a failure in providing appropriate respiratory care for the resident.
Failure to Document Resident Death and Notifications
Penalty
Summary
The facility failed to maintain complete medical records for a resident who died at the facility. The deficiency was identified when staff did not document full details and notifications related to the resident's death. The facility's policy on charting and documentation requires staff to document all pertinent changes in a resident's condition, including details surrounding a resident's death, such as code status, CPR performance, symptoms, vital signs, and notifications to the physician and family. However, the nursing notes for the resident did not include documentation of the resident's death or notifications to the physician and responsible parties. The resident, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and chronic kidney disease, was found without a pulse or heartbeat by aides. A Registered Nurse (RN) was informed and subsequently messaged the physician and called the resident's family but failed to document these actions in the progress notes. Interviews with the RN, Director of Nursing (DON), and Administrator revealed an expectation for staff to document changes in condition and notifications, which was not met in this case. The lack of documentation was confirmed during interviews, highlighting a failure to adhere to the facility's documentation policy.
Failure to Ensure CNA Certification Within Four Months
Penalty
Summary
The facility failed to ensure that six nurse aides (NAs) completed a certified nurse aide (CNA) training program and obtained certification within four months of employment. The NAs in question, identified as NA B, NA G, NA J, NA K, NA L, and NA C, were all found to be working at the facility without having completed the necessary certification. NA B, for instance, was rehired in December 2024 and was observed providing direct care to residents without being enrolled in a CNA class. Similarly, NA G, NA J, NA K, NA L, and NA C were all scheduled to work in the facility for several months without being listed on the state agency CNA registry. Interviews with the CNA Instructor and the Administrator revealed that there were no current nurse aide training classes at the facility, and the last class had concluded in September 2024. The CNA Instructor noted that nurse aides should become certified within 120 days or be reclassified, and they should work with another CNA or licensed nurse staff. The Administrator acknowledged that nurse aides should not work on the floor if certification is not obtained within four months and mentioned plans to relocate staff if necessary. However, the facility lacked a policy for nurse aide certification or training, contributing to the deficiency.
Infection Control Deficiencies in Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene practices during personal care for two residents. In the case of Resident #46, staff members did not wash or sanitize their hands after removing gloves and before putting on new gloves while performing perineal care. Similarly, for Resident #38, staff members also failed to sanitize or wash their hands after glove removal during perineal care, which involved handling soiled incontinence briefs and applying barrier cream. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing infection transmission. Additionally, the facility lacked a policy for Enhanced Barrier Precautions (EBP), which are infection control measures designed to reduce the transmission of resistant organisms. This deficiency was observed in the care of Resident #5, who had a diabetic ulcer and required EBP due to the presence of a wound. Despite the need for EBP, there was no signage indicating the precautions, and staff members, including the Infection Control Specialist and a Registered Nurse, failed to don gowns when providing direct care to the resident's wound. Interviews with staff members revealed a lack of understanding and inconsistent practices regarding EBP. Some staff members acknowledged the need for EBP signage and the use of gowns and gloves for residents with wounds, yet these measures were not consistently implemented. The absence of a formal EBP policy and the failure to adhere to proper infection control practices contributed to the facility's deficiency in maintaining an effective infection prevention and control program.
Controlled Medications Found Unsecured in Facility
Penalty
Summary
The facility failed to ensure that all controlled medications were stored according to standards of practice, as observed during a survey. Specifically, controlled substances such as Ativan Intensol and morphine sulfate were found in an unlocked refrigerator in the medication room. The facility's policy requires that controlled substances be stored under double-lock conditions and accessible only to authorized personnel. However, during observations on two separate occasions, the refrigerator containing these controlled substances was found unlocked, with the lock placed beside it on the counter. Interviews with staff revealed that there was an awareness of the requirement to keep the narcotics refrigerator locked, but lapses occurred. A Certified Medication Technician (CMT) acknowledged having seen the refrigerator unlocked and stated they would inform the Director of Nursing (DON) if it was found unlocked. A Registered Nurse (RN) admitted to forgetting to lock the refrigerator after counting narcotics with an off-going nurse. These actions and inactions led to the deficiency, as the facility did not adhere to its own policy for the secure storage of controlled substances.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse/neglect policy by not reporting an allegation of verbal abuse to the State Survey Agency within the required two-hour timeframe. The incident involved two residents, where one resident threatened to cut the throat of another resident during a smoke break. Despite the threat being heard by other residents and documented by a Registered Nurse (RN), the facility did not report the incident to the Department of Health and Senior Services (DHSS) as required by their policy. Resident #7, who made the threat, has a history of schizoaffective disorder, generalized anxiety disorder, and other behavioral issues, including delusions and hallucinations. The resident's care plan noted behavior problems such as inappropriate actions towards caregivers and other residents. Resident #35, the recipient of the threat, has moderate cognitive impairment and uses a wheelchair. The incident was documented in a nursing note, but there was no evidence of the allegation being reported to the DHSS. Interviews with various staff members, including the RN who documented the incident, revealed that they were aware of the requirement to report such allegations to the state within two hours. However, the Administrator stated she was not aware of the incident or the progress note documenting the threat. This lack of communication and failure to follow the facility's reporting policy resulted in the deficiency noted in the report.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse/neglect policy effectively, resulting in a lack of documented investigation into an allegation of verbal abuse involving two residents. The policy mandates that any resident abuse must be reported immediately to the administrator, who is responsible for conducting a thorough investigation. However, in this case, the facility did not document any investigation into the incident where one resident threatened another resident by saying, 'I will cut your throat.' This threat was witnessed by other residents, but no written investigation was provided to the Department of Health and Senior Services. Resident #7, who made the threat, has a history of schizoaffective disorder, generalized anxiety disorder, and intermittent explosive disorder, among other conditions. The resident's care plan noted behavior problems, including inappropriate behaviors towards caregivers and other residents. Despite these documented issues, the facility did not follow through with the required investigation after the threat was made. The nursing note from the incident indicated that the threat was reported to the administrator and Director of Nursing via text message, but no further action was documented. Interviews with various staff members, including registered nurses, certified nurse assistants, and the administrator, revealed a consensus that the threat constituted abuse and should have been reported and investigated. However, the administrator stated that she was not aware of the incident and that the required investigation was not completed. This lack of action and documentation represents a failure to adhere to the facility's abuse prevention and prohibition policy, leaving the incident unaddressed and unreported to the appropriate authorities.
Failure to Monitor and Manage Edema in Resident
Penalty
Summary
The facility failed to routinely monitor and manage a resident's edema, notify the physician of significant changes in the resident's condition, and apply prescribed interventions. The resident, who had diagnoses including schizophrenia, dementia, diabetes mellitus, and chronic venous hypertension, was not taking a diuretic and had an order for Tubi grips to be applied to the lower legs as needed for edema. Despite this, staff did not consistently document the application of Tubi grips or notify the physician of the resident's weight gain and changes in edema status. The resident's care plan required monitoring and reporting of edema or weight gain over two pounds a day, as well as weekly inspections of the lower extremities for signs of edema. However, the facility's records showed a lack of documentation regarding the application of Tubi grips and physician notification of the resident's weight increase and new redness on the feet. Observations revealed the resident had significant edema, with swollen and red legs, and was not consistently wearing Tubi grips. Interviews with staff indicated a lack of consistent application of Tubi grips and inadequate communication with the physician regarding the resident's condition. The resident's legs were observed to be swollen, red, and sometimes hot to the touch, with signs of possible cellulitis. Despite these observations, there was no documentation of physician notification or consistent application of prescribed interventions, highlighting a deficiency in the facility's care and monitoring processes.
Unsafe Resident Transfers Due to Non-Adherence to Care Plans
Penalty
Summary
The facility staff failed to ensure a safe environment free from accident hazards by not completing a safe transfer for two residents. Resident #46, who has diagnoses including dementia, polyarthritis, anxiety, and muscle weakness, required substantial assistance for transfers as per their care plan, which specified the use of a gait belt. However, during an observed transfer, staff did not use the gait belt and instead lifted the resident by holding onto the back of their pants, contrary to the care plan instructions. This improper transfer method was acknowledged by the staff involved, who noted the resident's limited weight-bearing capacity and the resident's upset reaction to the gait belt. Resident #38, with diagnoses of hemiplegia and hemiparesis following a stroke, was also involved in an unsafe transfer. The resident's care plan indicated the need for staff assistance during transfers, but did not specify the use of a gait belt. During an observed transfer, staff used a gait belt and lifted the resident with most of the weight on the resident's arms, despite the resident's severely impaired cognition and upper/lower extremity impairment. Staff interviews revealed that the resident was a two-assist transfer and should not have been transferred using a gait belt, as the resident did not bear weight. Interviews with the facility's RN and Administrator highlighted that transfers should be documented in the care plan and that changes in a resident's condition should prompt a reassessment by therapy. The Administrator emphasized that if a resident is not bearing weight, a mechanical lift should be used, and staff should seek assistance if unsure about transfer procedures. Despite these guidelines, the observed transfers did not adhere to the care plans or facility policies, resulting in unsafe transfer practices for the residents involved.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service, as observed during a lunch meal service. Nurse Assistant (NA) B was seen touching a resident's clothing and then handling a straw and a cup without performing hand hygiene. NA B continued to interact with residents and serve drinks without sanitizing hands, violating the facility's hand hygiene policy and the FDA's 2022 Food Code, which prohibits bare hand contact with ready-to-eat foods. Similarly, NA C was observed assisting a resident with eating by holding a piece of chicken with bare hands, further breaching the standards of practice. Interviews with various staff members, including dietary aides, the dietary manager, and the infection control specialist, confirmed that staff were expected to perform hand hygiene between serving residents and to use gloves when assisting with eating. Despite this, the observations showed a lack of compliance with these protocols, as staff members did not consistently sanitize their hands or use gloves, leading to potential contamination of food and food contact surfaces.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when 30 doses of alprazolam, a medication used to treat anxiety, went missing. The medication was ordered for a resident diagnosed with anxiety disorder, but it was not properly accounted for upon delivery. The Licensed Practical Nurse (LPN) signed for the medication delivery from the pharmacy but did not individually count or verify the medications, leading to the medication not being logged into the narcotic book or found in the facility. The Director of Nursing (DON) conducted an investigation and discovered that the medication was not delivered to the resident as expected. The Certified Medication Technician (CMT) responsible for putting away medications did not receive the alprazolam and noted that the pharmacy sometimes failed to provide a narcotic count sheet. Despite searching the medication carts and room, the medication was not located. Interviews with staff revealed that the LPN did not follow proper procedures for checking in medications, and the medication was not properly secured. The resident reported not receiving the medication and that it was being pulled from the emergency kit instead. The facility's investigation included notifying the Department of Health and Senior Services and the local police department about the missing medication. Despite these efforts, the facility was unable to determine what happened to the alprazolam, highlighting a failure in the facility's medication management and safeguarding procedures.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The CNA placed their hand close to the resident's mouth in an attempt to muffle the sound of the resident yelling during care. This action was reported by another Nursing Assistant (NA) who was present during the incident. The NA stated that the resident was yelling, which was normal behavior for them, and the CNA responded by telling the resident to shut up and placing their hand near the resident's mouth. The resident involved had severe cognitive impairment and required maximum assistance from staff for various activities, including personal hygiene and mobility. The resident's care plan noted that they could become combative and yell out inappropriately at times. During the incident, the CNA claimed they were trying to block the sound to hear the NA better and accidentally touched the resident's chin with their glove. Despite the CNA's explanation, the facility's investigation concluded that the resident was not treated with dignity and respect. Interviews with other staff members, including the Director of Nursing (DON) and Business Office Manager (BOM), confirmed that the CNA's actions were inappropriate and did not align with the facility's policy on treating residents with dignity and respect. The staff members emphasized that residents should be treated like family and that it is never appropriate to place a hand in front of a resident's face to muffle sound. The incident highlighted a failure in maintaining the resident's right to a dignified existence and respectful treatment.
Failure to Protect Resident's Personal Belongings from Misappropriation
Penalty
Summary
The facility failed to protect a resident's personal belongings from misappropriation when a staff member had possession of the resident's cellular phone without consent. The resident, who had moderate cognitive impairment and was dependent on staff for various activities, had their phone reported missing by a family member. Despite staff efforts to locate the phone, it was not found initially. Another nurse assistant later reported suspicions that a colleague might have stolen the phone and given it as a gift to their child. The phone was eventually returned to the facility and confirmed to belong to the resident by the cellular provider. The nurse assistant suspected of taking the phone denied any involvement but was suspended pending investigation and subsequently terminated. The facility reported the incident to the Department of Health and Senior Services and the local police department. The deficiency highlights a failure in the facility's policy to prevent misappropriation of resident property and ensure that staff members with a history of such actions are not employed.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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