Springfield Skilled Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 2401 West Grand, Springfield, Missouri 65802
- CMS Provider Number
- 265477
- Inspections on file
- 54
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Springfield Skilled Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, kidney disease, and a ureteral stent in place refused multiple times to attend a scheduled urology follow-up appointment for stent removal. The CNA responsible for transport reported the refusals and stated a nurse also spoke with the resident, but there was no documented order for the appointment and no documentation that the resident’s guardian or physician were notified. The urology clinic recorded the resident as a no-show and reported no contact from the facility about the missed visit, despite later sending a letter. Staff interviews, including from CNAs, LPNs, the NP, social services, the DON, and the administrator, confirmed that the resident had a guardian, that the resident could not make major medical decisions, and that facility policy and expectations required notifying the guardian and provider and documenting refusals of appointments. Record review showed this notification and documentation did not occur, resulting in a deficiency related to failure to immediately inform the resident’s representative and physician of a significant event affecting the resident’s care.
A resident with diabetes, peripheral arterial disease, and an infected arterial wound to the left shin was admitted with extensive leg wounds requiring complex care. Over several weeks, the wound physician repeatedly recommended and/or ordered deep wound cultures and an X-ray of the affected leg to evaluate for infection and osteomyelitis, and an order for a wound culture appeared on the TAR. Nursing staff did not obtain or document any wound culture or X-ray results, and one LPN acknowledged not performing the ordered culture, citing lack of swabs. As the wound enlarged and showed necrotic tissue, purulent drainage, foul odor, and signs of infection, an RN documented significant decline and increased pain but chose to wait until after the weekend to notify the physician, contrary to the facility’s change-in-condition policy and the resident’s care plan directives. The resident was later noted to have systemic symptoms and was sent to the hospital, where an extensive infected lower extremity wound with necrosis and cellulitis was documented, leading to a plan for amputation.
Multiple residents experienced significant medication errors when staff failed to accurately transcribe and follow hospital discharge and physician orders for digoxin, warfarin, insulin, and psychotropic medications. For a resident with CHF and recent MI, an LPN entered a digoxin order as 125 mcg QID instead of once daily, and staff administered it at that frequency for several days despite system warnings and clinical signs such as lethargy, nausea, vomiting, hypotension, and bradycardia, culminating in documented digoxin toxicity and ICU admission. Another resident with paraplegia and a history of thrombosis received warfarin 3 mg daily rather than the ordered variable dosing of 3 mg on one day and 2 mg on other days, as specified on the hospital discharge summary. Additional residents received less insulin and fewer blood glucose checks than recommended, and psychotropic medications were not administered as ordered. These errors occurred despite facility policies requiring verification of admission/readmission orders, adherence to prescriber directions, and clarification of unusual doses.
Nursing staff failed to maintain an effective reconciliation system for controlled substances when two nurse medication carts, containing all PRN controlled meds, lacked signature sheets for beginning and end of shift narcotic counts. Although nurses reported that off-going and oncoming staff verbally counted the quantity of each controlled medication and total packages on the Skilled 1 and Skilled 2 carts, they did not sign to confirm these counts and had never done so during their months of employment. Review of the controlled medication books confirmed the absence of signature sheets, and both the DON and Administrator stated that nurses were expected to sign each shift to verify completion and accuracy of narcotic counts, but the DON had not been auditing to ensure this occurred.
The facility failed to honor residents’ rights to timely access their personal trust funds by limiting withdrawals to $35.00 per day and requiring 48‑hour advance written requests for larger amounts, despite a written policy stating that requests of $50.00 or less would be honored the same day. Two cognitively intact residents who managed their own affairs reported needing to make multiple trips or complete forms and wait two days to obtain their full $50.00 monthly funds. Business office staff and the BOM confirmed the $35.00 daily limit and advance request requirement, citing a $2,000.00 cash box limit and internal policy rather than regulation, while the Administrator stated they could not give every resident their full $50.00 at once and referenced corporate direction and Social Security payee rules over CMS guidelines.
Surveyors identified that staff did not consistently administer medications as ordered, resulting in a medication error rate above 5%. One resident with diabetes, restless leg syndrome, and fibromyalgia received a double dose of a cholesterol medication when a CMT pulled two 20 mg tablets from different packaging, and the same resident did not receive an ordered Ropinirole ER dose because it was not available and no explanatory nurse note accompanied the MAR entry. Another resident with insulin‑dependent diabetes and COPD did not receive ordered Advair Diskus and Prednisone doses when a CMT could not locate either medication and reported they were on order from the pharmacy. Staff interviews, including CMTs, LPNs, the DON, and the Administrator, described recurring problems with medication availability, delayed pharmacy deliveries, and inconsistent re‑ordering practices, contributing to these administration failures.
A resident with COPD, diabetes, bipolar disorder, malnutrition, and anxiety, who was cognitively intact and his/her own responsible party, was sent to the hospital, but the nurse’s progress notes contained no documentation of a change in condition, the need for transfer, or physician notification. The resident’s care plan required monitoring and documentation of symptoms related to hypoglycemia, hyperglycemia, infection, and psychotropic/antianxiety medication effects, as well as behavioral symptoms. Facility leadership and nursing staff (including the ADON, an RN, and an LPN) stated that standard practice is for the charge nurse to document symptoms, vitals, and notifications to the physician and responsible party when a resident is transferred, but this was not done in this case.
A resident with a history of encephalopathy, cerebral infarction, and diabetes developed facility-acquired pressure ulcers due to the facility's failure to provide timely and appropriate wound care. The resident's condition worsened as staff did not consistently document wound treatments or update the care plan, leading to infection and a referral for possible amputation. Lab tests recommended to monitor the resident's condition were not completed, contributing to the deterioration of the resident's health.
A resident with epilepsy suffered a burn after spilling hot coffee, potentially due to a seizure. The facility failed to document and follow physician's orders for wound care, leading to the burn worsening and requiring a skin graft. Staff interviews revealed a lack of communication and documentation regarding the incident and treatment.
A resident in an LTC facility was hospitalized due to a benzodiazepine overdose after the facility failed to discontinue Xanax when Valium was started, despite system warnings. The resident, on multiple medications with Black Box Warnings, was not properly monitored for side effects, and staff did not notify the physician of the errors. Interviews revealed a lack of communication and adherence to medication policies.
The facility did not meet the required minimum of six staff members attending the Quality Assessment and Assurance (QAA) meetings, as per their Quality Assurance Process Improvement (QAPI) policy. The meetings consistently had only four attendees, and on two occasions, only three. The Administrator was unaware of the requirement for a minimum number of staff to attend, leading to this deficiency.
The facility failed to document and assess the use of bed rails for several residents, leading to potential safety risks. A resident reported loose bed rails, but there was no documented maintenance request or follow-up. Two residents had side rails without documented assessments, informed consent, or inclusion in care plans. Staff interviews revealed confusion about responsibilities for bed rail assessment and maintenance.
A facility failed to ensure residents only self-administer medications after assessment by an interdisciplinary team. A resident was found with medications left on their bedside table without an assessment or physician's order. Staff interviews revealed a pattern of leaving medications at the bedside, contrary to policy. The DON and Administrator confirmed no residents had orders for self-administration, highlighting a deficiency in adherence to protocols.
The facility failed to provide required Medicare notices to two residents when their Medicare-covered services were ending. A resident did not receive the NOMNC, and another received a blank SNFABN form without necessary dates and signatures. Interviews revealed a lack of training and oversight, with the Social Service Designee being new and the Administrator unaware of the incomplete notices.
A facility failed to obtain and maintain a Level II PASRR for a resident with multiple mental health diagnoses, including anoxic brain damage and bipolar disorder. The resident was admitted without the necessary documentation, and staff interviews revealed confusion over responsibility for PASRR completion. The Social Services Director could not locate the Level II PASRR, and the DON noted that the admissions nurse, who no longer worked there, usually handled PASRRs. The Administrator confirmed the need for completed PASRRs in residents' records.
A facility failed to obtain an order and care plan for a resident's ankle foot orthotic (AFO) brace, which was necessary for mobility due to conditions like cerebral infarction and hemiplegia. Despite the resident's consistent use of the brace, there was no formal documentation or monitoring plan in place. Staff interviews revealed a lack of clarity and formal guidance on the brace's application and monitoring, highlighting a deficiency in meeting professional standards of practice.
A facility failed to complete a discharge summary for a resident with paraplegia and other conditions, who was planning to discharge home with home health services. Despite the facility's policy requiring documentation, the discharge summary and progress notes were not completed, as confirmed by interviews with staff including an LPN, the DON, and the Administrator.
A resident with moderate cognitive impairment and dependency on staff for personal hygiene was not provided adequate bathing, receiving only one shower since admission. The facility failed to document bathing attempts or refusals, and there was no care plan addressing the resident's need for assistance with bathing. Staff interviews revealed inconsistencies in documentation and communication regarding the resident's bathing schedule and preferences.
A resident with a history of seizures suffered burns from a coffee spill in a LTC facility. The facility failed to complete a timely investigation or update the resident's care plan with new interventions to prevent future burns. Staff interviews revealed inconsistent procedures for monitoring and assisting residents with hot beverages, contributing to the deficiency in maintaining a safe environment.
A resident returned from the hospital with a Foley catheter, but the facility failed to obtain a physician's order for its use or document the medical necessity. The resident's care plan was not updated timely, and staff did not consistently document catheter care and output monitoring. Interviews revealed inconsistencies in following catheter management protocols, leading to a deficiency in care.
The facility failed to provide adequate respiratory care for two residents by not adhering to physician orders for oxygen equipment maintenance. A resident's care plan did not include oxygen use, and staff failed to document required changes to oxygen equipment. Observations showed undated oxygen tubing and humidifiers, indicating non-compliance with prescribed schedules. Interviews with staff confirmed expectations for weekly changes, but the facility's policy lacked guidance on oxygen equipment care.
A resident suffered a burn from spilled coffee, but the facility failed to document the incident and assess the burn in accordance with its policy. The resident, who was cognitively intact, believed a seizure caused the spill. Initial assessment noted a reddish area, but no measurements or detailed documentation were made. The resident was sent to the hospital for further treatment, revealing a lack of adherence to documentation policies by the facility staff.
The facility failed to maintain a working call light system for two residents, affecting their ability to request assistance. The call light system was malfunctioning, with the indicator light continuously blinking and not alerting the nurses' station. Residents were provided with bells as an alternative. Staff interviews revealed a lack of awareness and communication regarding the issue, with maintenance unaware due to no work order being submitted.
The facility failed to maintain current and complete survey results in an accessible location for residents and their representatives. A binder with survey results was found near the TV area, but it lacked results from the previous three years, including the last recertification survey. Interviews with residents and staff revealed a lack of awareness and knowledge about the location of these results, with the Administrator admitting responsibility for the oversight.
The facility failed to post daily nurse staffing information in a prominent location accessible to residents and visitors, as required by policy. Observations showed the staffing sheet was not updated daily and was sometimes missing. Interviews with the DON and Administrator revealed a lack of awareness and oversight regarding the posting responsibilities, with the task sometimes falling to charge nurses and the ADON, who was new or absent for a period.
A facility failed to provide a written discharge notice to a resident who was not allowed to return after hospitalization. The resident, with multiple diagnoses including schizophrenia and bipolar disorder, exhibited behavioral issues leading to hospital visits. Despite these events, the facility did not issue a required discharge notice, as confirmed by staff interviews.
The facility experienced significant staffing shortages, resulting in delayed responses to call lights and inadequate care for residents. Observations and interviews revealed that residents often waited extended periods for assistance, with some left in soiled briefs for hours. Staffing levels were insufficient, particularly on the 100, 200, and 300 halls, leading to prolonged wait times for essential care. Staff acknowledged the understaffing issues, and residents expressed dissatisfaction with the delays.
A resident with a history of falls and moderate cognitive impairment was subjected to inappropriate treatment by an LPN, who raised their voice and used profanity after the resident fell while being escorted to the smoking area. The LPN's actions violated the facility's policy on resident rights, which requires staff to treat residents with kindness, respect, and dignity. Witnesses confirmed the LPN's inappropriate behavior, and staff acknowledged that such actions should be reported to supervisory personnel.
The facility failed to maintain a fully functional call light system, affecting two residents with moderate cognitive impairment who required substantial assistance. One resident was left in a wet brief for hours due to a non-functioning call light, while another was left on the toilet for an extended period. Staff acknowledged issues with the call light system, which led to delays in care despite the presence of backup bells.
The facility did not report an anonymous allegation of verbal and mental abuse by CNA A to DHSS within the required two-hour timeframe. Despite receiving a report from the corporate office about CNA A's inappropriate behavior, including smoking a weed pen on duty and verbally abusing residents, the facility did not report this to DHSS. The DON suspended CNA A pending investigation, but the Administrator did not report the allegations, believing the investigation showed no abuse.
A deficiency was identified due to the facility's failure to provide a safe, clean, comfortable, and homelike environment for residents, including the safe provision of treatment and daily living supports. This was documented under event ID JJ94112 with specific citations MO00240384 and MO00240390.
A deficiency was identified due to the failure to develop a complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A deficiency was identified where residents did not receive necessary assistance with activities of daily living. This failure was noted during a survey, highlighting specific cases where residents were left without the required support.
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, as identified in a survey with event ID JJ94112.
The facility was cited for failing to implement an effective infection prevention and control program, as identified during a survey event. This deficiency was noted under event ID JJ94112, indicating lapses in infection control practices.
The facility failed to maintain proper documentation and timely destruction of discontinued medications, including controlled substances, for multiple residents. Observations revealed a large quantity of medications awaiting destruction in the medication room and the DON's office. Staff interviews indicated a lack of clarity and adherence to policies, with no specific timeframe for medication destruction and missing accountability records.
The facility did not ensure a clean and homelike environment for its residents, as staff failed to clean the floor of a resident's room adequately and in a timely manner, and did not change soiled bedding for a resident. This was identified through observation, interview, and record review, with the facility census at 110.
The facility did not update a resident's care plan to include new communication strategies after the resident returned from the hospital, nor did it ensure all staff were informed of this change. The facility's census was 110.
The facility did not ensure proper grooming and personal hygiene for a resident, as staff failed to routinely change urine-soaked clothing and complete bathing or showering. This deficiency was observed in a facility with a census of 110 residents.
A facility failed to maintain an environment free from accident hazards by not placing the call light within reach of a resident, as outlined in their care plan for fall prevention. This issue was identified through observation, interview, and record review.
A facility failed to maintain an effective infection control program when staff did not promptly clean urine from a resident's floor, leading to contamination being spread through the facility. A resident was left with bare feet in the urine, and a blood pressure monitor was used on the resident without being cleaned after contact with the floor.
A resident with moderate cognitive impairment was found in a room with unsanitary conditions, including a floor covered in dried liquid and feces under the bed. The resident's bed was also dirty and smelled of urine. Staff interviews revealed confusion and inconsistency regarding cleaning responsibilities, with housekeeping short-staffed and nursing staff expected to clean rooms. Facility policies on room cleaning were not followed, leading to the observed deficiencies.
A resident returned from the hospital with new communication needs due to severe cognitive impairment and hearing difficulties. The facility failed to update the care plan to include the hospital's recommendation of writing questions on paper for effective communication. The MDS Coordinator did not update the care plan, and the staff was not adequately informed, leading to a deficiency in person-centered care.
A facility failed to maintain a resident's hygiene and dignity by not ensuring regular bathing and changing of urine-soaked clothing. The resident, with severe cognitive impairment, required assistance with ADLs, but staff did not consistently document or follow through with care. Observations showed the resident in soiled clothing, and staff interviews revealed inadequate communication and documentation practices.
A resident with multiple health conditions was left without access to a call light, contrary to their care plan for fall prevention. Despite staff presence, the call light remained out of reach, and the resident was later assessed for signs of congestive heart failure exacerbation. Staff interviews confirmed the expectation that call lights should always be within reach, but no policy was provided by the facility.
A resident in an LTC facility experienced significant medication administration errors due to the lack of a system to document timely administration. The facility did not have a policy for a liberalized medication administration system, nor did it train staff on such a system. The resident, with multiple diagnoses, received medications like Creon, oxycodone, diazepam, and gabapentin at incorrect times, often hours late or simultaneously with other doses, leading to the deficiency.
A facility failed to implement an effective infection control program when staff did not promptly clean a urine spill involving a resident. The incident involved a resident sitting in a wheelchair with urine dripping onto the floor, which staff members, including the DON, CNA, and RN, stepped in without cleaning their shoes. Additionally, a blood pressure monitor was dropped on the floor near the urine and used on the resident without being sanitized. Interviews revealed staff's lack of adherence to infection control protocols, contributing to the deficiency.
The facility failed to maintain effective infection control as staff did not don appropriate PPE or perform hand hygiene when entering and exiting isolation rooms of residents with influenza A. Observations and interviews revealed multiple instances of non-compliance with infection control protocols, despite clear signage and availability of PPE.
The facility failed to maintain a clean and homelike environment when staff did not address black substances on the walls and ceiling in a resident's room. The resident required assistance with daily living activities and had a pulmonary disease. Despite observations and reports by staff, the issue remained untreated, indicating a breakdown in communication and procedural adherence.
Failure to Notify Guardian and Physician of Resident’s Refusal of Stent Removal Appointment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s guardian and physician when the resident refused a scheduled medical appointment for removal of a ureteral stent. The facility’s policy on Notification of a Change in Condition required that the attending physician or extender and the resident representative be notified of changes in condition, including significant changes and refusals of prescribed treatments, and that such notifications be documented in the interdisciplinary team notes. Surveyors found that for one resident, staff did not document any notification to the responsible party or physician when the resident refused a scheduled urology appointment for stent removal. The resident involved had a diagnosis of hydronephrosis with ureteropelvic junction obstruction, a history of kidney disease with acute renal failure, and a cognitive communication deficit. The resident’s MDS showed severely impaired cognitive skills, and the care plan documented impaired cognitive function related to vascular dementia and traumatic brain injury, with instructions to communicate with the responsible party about the resident’s capabilities and needs and to report changes in cognitive function to the physician. The resident had undergone lithotripsy and a stent exchange in late October, and a follow-up appointment was scheduled at a urology clinic for removal of the ureteral stent. The urology clinic’s medical assistant reported that the resident was a no-show for the follow-up appointment and that there was no documentation of the facility calling about the missed appointment; the clinic later sent a letter to the facility and received no response. On the date of the scheduled follow-up, the CNA/transport staff responsible for appointments stated that the resident refused three times to go to the post-operative appointment for stent removal, and that a nurse also spoke with the resident, who stated they were not going and that “they aren’t touching me.” The CNA reported calling the urology clinic and leaving a message but did not follow up further and made no additional appointments. Review of the resident’s records, including the POS, MAR, TAR, and progress notes, showed no documented order for the scheduled urology appointment and no documentation that the resident’s guardian or physician were notified of the refusal. The resident’s public administrator caseworker, who served as guardian, stated the resident was under guardianship, did not have the ability to make medical decisions, and that he would have wanted to be informed of the refusal and would have directed that the resident be sent to the appointment or to the hospital if necessary. Multiple staff interviews confirmed that the resident had a guardian and that, per facility expectations, refusals of appointments should be documented and communicated to the guardian and provider. The CMT, LPNs, NP, social services staff, DON, and administrator each indicated that if a resident with a guardian refused an appointment, staff should notify the guardian and provider and document the refusal in the record. The NP and physician both reported they were not aware at the time that the resident had refused the stent removal appointment. The DON stated she found no notes or communication to the physician or NP about the refusal and confirmed that CNA B was responsible for scheduling and transporting residents to appointments, with nurses expected to document refusals and notifications. Despite these expectations and policies, there was no documentation that the resident’s guardian or physician were notified of the refusal of the scheduled urology appointment for stent removal. Subsequently, several months later, the resident was sent to the emergency department after staff noted the resident “did not act right,” and the on-call provider directed that the resident be sent out. Hospital paperwork documented a history of UTIs and a complicated UTI requiring a stent, with prior lithotripsy and stent exchange. However, the deficiency cited by surveyors centers on the earlier failure to notify the resident’s guardian and physician and to document that notification when the resident, who was under guardianship and had severely impaired cognition, refused the scheduled appointment for removal of the ureteral stent.
Failure to Follow Wound Physician Orders for Cultures, Imaging, and Change-in-Condition Notification
Penalty
Summary
The deficiency involves the facility’s failure to follow wound physician recommendations and treatment orders for a resident with a severe vascular wound to the left shin. The resident was admitted with traumatic ischemia of muscle, peripheral arterial disease, diabetes mellitus type II, deep vein thrombosis, and existing venous/arterial ulcers, and was cognitively intact but dependent on staff for most activities of daily living. The care plan identified an infected arterial wound to the left shin and directed staff to perform wound treatments per current orders, assess for signs and symptoms of infection with each dressing change, and report any positive findings or lack of response to treatment to the physician. The facility’s policy on notification of change in condition required licensed nursing staff and nursing administration to notify the attending physician or nurse practitioner of changes in a resident’s condition. Beginning on 10/02/25, the wound physician’s report documented an infected left shin wound present on admission, with significant slough, odor, erythema, and purulent drainage, and specifically recommended obtaining a deep wound culture. Subsequent weekly wound reports dated 10/09/25, 10/16/25, and 10/23/25 continued to recommend a wound culture, and later reports on 10/30/25, 11/14/25, 11/21/25, and 11/26/25 added recommendations for an X-ray of the left shin/leg to evaluate for osteomyelitis. Despite these repeated recommendations, the resident’s medical record contained no documentation of wound culture results or X-ray results. An LPN acknowledged that an order dated 10/02/25 to obtain a wound culture appeared on the treatment administration record and that he/she documented “NA” and did not obtain the culture, stating he/she could not locate culture swabs. The DON and Administrator later confirmed they were unable to find any wound culture or X-ray results in the record and that such orders should have been carried out and documented. As the wound progressed, multiple assessments documented worsening characteristics and ongoing infection. On 11/14/25, a different wound physician noted a larger wound with necrotic and devitalized tissue, odor of pseudomonas, and recommended referral to a vascular surgeon along with wound culture and X-ray. On 11/26/25, the wound nurse documented a full-thickness arterial wound with necrotic tissue, moderate purulent drainage, and stated that diagnostic studies including X-ray and deep wound cultures were pending, yet no results were recorded. On 11/28/25, an RN documented that the wound had declined, with more drainage, foul odor, and increased pain, and wrote that he/she would inform the physician of these changes on the following Monday rather than immediately. The next day, another nurse documented the resident was lethargic with nausea, vomiting, chills, shaking, and excessive green purulent drainage with foul smell from the left shin wound, and the resident was sent to the emergency department. Hospital records described an extensive infected left lower extremity wound with necrosis and cellulitis, and the plan included proceeding with amputation. Interviews with nursing staff and leadership confirmed that the physician was not notified of the 11/28/25 change in condition at the time it occurred and that ordered or recommended wound cultures and X-rays were not obtained or documented, leading to the cited deficiency for failure to provide treatment and care according to orders and physician recommendations. Interviews further clarified the sequence of inactions contributing to the deficiency. The wound nurse stated that he/she routinely reviewed the wound physician’s after-visit summaries and entered new or changed orders into the electronic medical record, and that the facility had completed topical treatments as ordered, but acknowledged the leg was necrotic with pus and odor from admission and that the wound physician anticipated the need for amputation. An RN reported that on the day before the resident was sent to the hospital, the wound was covered in moist eschar with yellow-green drainage and foul odor, but he/she did not call the physician, believing the wound physician was already aware and that the situation could wait until after the weekend. Another nurse who arranged the hospital transfer relied on a colleague’s report of the wound condition and was not aware of any wound culture orders. The DON and Administrator both stated that nurses should have obtained ordered cultures within the same shift, notified providers promptly of changes in condition, and ensured that wound physician recommendations for cultures and X-rays were entered and completed, but the record and staff interviews showed this did not occur for this resident. Overall, the deficiency centers on the facility’s failure to implement and document wound physician recommendations for deep wound cultures and diagnostic imaging over multiple weeks, and failure to promptly notify a physician or nurse practitioner when the resident’s wound and overall condition worsened. These failures occurred despite clear care plan directives to monitor and report wound changes and a facility policy requiring provider notification of changes in condition. The absence of culture and X-ray results in the medical record, the LPN’s admission that a culture was not obtained despite an order, and the RN’s decision to delay notifying the physician about significant wound decline until after the weekend collectively demonstrate the inactions and missed interventions that led to the cited deficiency for not providing appropriate treatment and care according to orders and the resident’s needs.
Significant Medication Errors from Incorrect Order Transcription and Failure to Follow Prescriber Directions
Penalty
Summary
The deficiency involves multiple failures to ensure residents were free from significant medication errors, primarily related to inaccurate transcription and implementation of physician and hospital discharge orders. For one resident with a recent heart attack, CHF, COPD, diabetes, and severe cognitive impairment, the hospital discharge order for digoxin was 125 mcg by mouth once daily. Upon readmission, an LPN entered the order into the electronic record as 125 mcg four times daily, which did not match the hospital order. The physician order sheet and MAR reflected this incorrect frequency, and the system generated notes indicating the dose and frequency were outside usual recommended ranges, but there was no documented follow-up with the physician. The resident’s MAR showed missed doses initially due to medication unavailability without documented physician notification, followed by consistent administration of digoxin four times daily over several days. During this period, secure messages documented that nursing staff reported the resident was sleeping a lot, had low BP, poor appetite, and low energy, and that labs were drawn, but there was no immediate correction of the digoxin order. The resident’s digoxin level later returned critically high (greater than 5 ng/mL), and staff confirmed that the admission nurse had entered the order incorrectly as four times daily instead of once daily. The resident exhibited lethargy, confusion, nausea, vomiting, poor intake, hypotension, weak and thready pulses, and low heart rates, with multiple vital sign entries showing bradycardia and hypotension. The resident was ultimately sent to the hospital, where documentation indicated admission for altered mental status, hypotension, and digoxin toxicity with a digoxin level of 6.6 ng/mL, and treatment with Digibind and vasopressors in the ICU. Interviews with staff revealed that the LPN who entered the order did not realize it did not match the hospital discharge order, did not notify the physician of the resident’s return, and assumed the physician would review the orders, while other staff acknowledged that digoxin is typically given once daily and that the wrong dose was discovered only after the critical lab result. Another resident with paraplegia, lumbar spina bifida, and a history of thrombosis and embolism had a hospital discharge order for warfarin 1 mg tablets, with instructions to administer 3 tablets on Mondays and 2 tablets on all other days, and to hold the dose on the day of discharge pending a PT/INR recheck. When this resident was readmitted, the physician order sheet instead showed warfarin 1 mg, 3 tablets by mouth once daily starting the following day, without the variable dosing schedule specified by the hospital. The MAR reflected a daily 3 mg dose at 9:00 A.M., and staff documented administration of this dose every day over the remainder of the month. Although the care plan and nurse MAR included monitoring for anticoagulant side effects and staff documented monitoring twice daily, the warfarin order as transcribed and administered did not match the hospital discharge instructions, resulting in the resident receiving a higher total weekly dose than ordered by the hospital and not following the specified dosing pattern tied to PT/INR monitoring. The report also notes additional deficiencies for other residents, including failure to follow physician recommendations for changes to insulin dosing and blood sugar checks for one resident, resulting in administration of less insulin and fewer blood glucose checks than recommended, and failure to administer psychotropic medications as ordered for another resident. The facility’s own policies required that admission/readmission orders be obtained and verified on the day of admission, that medications be administered exactly as prescribed, that MAR entries be compared with prescriber orders, and that unusual doses or directions be clarified with the prescriber or pharmacy and documented. Interviews with the ADON indicated uncertainty about whether nurses communicated admission/readmission orders to the physician or performed any second check on orders for accuracy. Collectively, these actions and inactions led to significant medication errors involving digoxin, warfarin, insulin, and psychotropic medications for multiple residents.
Lack of Documented Shift Counts for PRN Controlled Medications
Penalty
Summary
Failure to maintain an effective system for reconciliation of controlled substances occurred when nursing staff did not document shift-to-shift narcotic counts for two medication carts, identified as Skilled 1 and Skilled 2, which contained all PRN controlled medications for residents. Surveyor review of the controlled medication books on each cart showed there were no signature sheets for nurses to sign when counting controlled medications at the beginning and end of each shift. Observation showed the two medication carts were located inside the locked nurse station and contained PRN controlled medications for the facility’s 106 residents. During interviews, two LPNs stated that at the beginning and end of each shift, the off-going and oncoming nurses counted the quantity of each controlled medication and the total number of controlled medication packages on their assigned carts, but they did not sign to confirm the shift count. Both LPNs reported they had worked at the facility for several months and had never signed to confirm beginning and end of shift counts. The DON stated that nurses were expected to count all controlled medications and sign a signature sheet each shift to confirm the count was correct, but acknowledged being unaware that nurses were not signing and that audits were not being done to ensure compliance. The Administrator also stated that nurses should be signing for completion and accuracy of the narcotic count at the beginning and end of each shift.
Failure to Provide Timely Access to Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ requests for access to their personal funds in accordance with its own policy and regulatory requirements. The facility’s written Resident Trust Fund Policy states that residents who choose to have a trust fund account have the right to have their money safeguarded and to access any requested funds of $50.00 or less the same day. Two cognitively intact residents, both their own responsible parties, reported that although they received $50.00 per month and kept their funds in the resident trust account, they were limited to withdrawing $35.00 per day. One resident stated they had to go to the facility bank twice to obtain $50.00, receiving $35.00 one day and $15.00 the next, and that if they wanted to withdraw $50.00 they had to complete a form for the Business Office Manager and wait two days. Another resident reported that if they needed more than $35.00, they were required to fill out a request form 48 hours in advance and were unsure how they would obtain the full $50.00 without advance notice. Interviews with staff confirmed that the facility had implemented a practice limiting residents to $35.00 per day from their trust accounts, with larger amounts requiring a written request 48 hours in advance. The Business Office Assistant stated residents were allowed to withdraw $35.00 per day and did not know why this limit existed, and that requests for more than $35.00 required a 48‑hour advance form. The Business Office Manager explained that residents withdrew money from a window by the activity room, could withdraw up to $35.00 per day, and that requests for more than $35.00 required a form so the manager could go to the bank because the facility’s cash box could not hold that much money and was limited to $2,000.00. The Business Office Manager acknowledged that the $35.00 limit was a facility policy, not a regulation, and was based on concerns about having too much cash on hand. The Administrator stated that when residents came to the facility bank, the facility could not give every resident their full $50.00 and reported being told by the corporation that if the facility was the payee for a resident’s Social Security, the resident could only be given $10.00 a day and that Social Security rules were followed over CMS guidelines.
Medication Administration Errors and Unavailable Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and to maintain a medication error rate below 5%, as required by regulation and facility policy. During a medication pass observation, staff made 4 errors out of 27 opportunities, resulting in a 6.75% medication error rate. The facility’s own policy required adherence to the five rights of medication administration, use of the MAR during administration, verification of orders when questions arose, and timely action when medications were unavailable, but these standards were not met in multiple instances. For one resident with diagnoses including type II diabetes mellitus, restless leg syndrome, and fibromyalgia, the physician had ordered Rosuvastatin 20 mg by mouth in the morning for hyperlipidemia and Ropinirole ER 4 mg once daily for restless leg syndrome. During observation, a CMT removed one 20 mg Rosuvastatin tablet from a plastic strip and another 20 mg tablet from a bubble pack, both labeled for that resident with the same prescription, and placed both tablets in the medication cup, administering double the ordered dose. During the same pass, the CMT was unable to locate the ordered Ropinirole ER 4 mg in the medication cart or emergency kit and informed the nurse, who stated he or she would contact the pharmacist; the medication was not available for administration as ordered. The MAR showed the Ropinirole dose previously documented as not administered with an “NA” code, but there was no corresponding nurse note explaining the reason for non‑administration. For another resident with insulin‑dependent type II diabetes and COPD, physician orders included Advair Diskus 250/50 mcg, one inhalation twice daily, and Prednisone 5 mg by mouth in the morning for COPD. During observation, a CMT could not locate the Advair Diskus inhaler and stated an intention to ensure it was ordered from the pharmacy. The same CMT reported that the 5 mg Prednisone tablet was also not available, stating the facility had ordered it and was waiting for delivery. Neither medication was available for administration as ordered during that medication pass. The MAR documented the Advair dose as not administered (“NA”) and the Prednisone dose as held (“HD”), with progress notes indicating the medications were on order. Multiple staff interviews, including CMTs, LPNs, the DON, and the Administrator, confirmed recurring issues with medication availability, delays in pharmacy delivery, inconsistent re‑ordering by CMTs, and uncertainty about nurses’ verification of physician orders, all contributing to residents not receiving ordered medications as prescribed.
Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s change in condition and subsequent transfer to the hospital in the nursing progress notes. The resident was cognitively intact, was his/her own responsible party, and had multiple diagnoses including COPD, bipolar disorder, extrapyramidal and movement disorder, anxiety, insomnia, diabetes mellitus, malnutrition, and shortness of breath. The resident’s care plan, revised on 12/15/25, directed staff to monitor, document, and report signs and symptoms related to hypoglycemia, hyperglycemia, infection, and adverse reactions to psychotropic and antianxiety medications, as well as to record occurrences of target behavioral symptoms. The census showed the resident went on hospital leave on 12/27/25. Record review showed there was no nurse’s progress note documenting a change in condition, the need for hospital transfer, or physician notification on the date the resident was sent to the hospital. Interviews with the ADON, an RN, an LPN, and the Administrator confirmed that the facility’s expectation and practice were that the charge nurse document in the nurse’s progress notes the resident’s symptoms, concerns, vital signs, and notifications to the physician and responsible party whenever a resident is sent to the hospital. Despite these stated procedures, such documentation was absent for this resident’s hospital transfer.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for a resident, leading to the development of facility-acquired pressure ulcers and subsequent infection. The resident, who had a history of encephalopathy, cerebral infarction, non-pressure ulcer of the right foot, and type two diabetes mellitus, was admitted to the facility and initially had no documented wounds. However, a pressure ulcer was later discovered on the resident's right heel, which was not promptly assessed or treated according to physician orders. The facility staff failed to document wound treatments consistently, and the resident's care plan was not updated to reflect the presence of the wounds or changes in treatment. The resident's condition deteriorated as the pressure ulcer progressed from stage 3 to unstageable, with necrotic tissue and infection present. Despite recommendations for lab tests to monitor the resident's condition, these were not completed, and the care plan was not updated to address the new treatment interventions. The resident experienced increased pain and was eventually referred to a surgeon for possible amputation due to the severity of the infection and osteomyelitis. Throughout the resident's stay, there were multiple instances where staff did not document the completion of wound treatments as ordered, and the resident's care plan was not adequately updated to reflect the ongoing changes in the resident's condition. The lack of timely and appropriate wound care, documentation, and care planning contributed to the resident's worsening condition and the need for surgical intervention.
Failure to Provide Adequate Wound Care and Documentation
Penalty
Summary
The facility failed to provide care per physician's orders and professional standards of practice for a resident who suffered a burn. The incident occurred when the resident, who has a history of epilepsy, spilled hot coffee on their left thigh, potentially due to a seizure. The initial assessment by the nursing staff noted redness and warmth on the affected area, but there was a lack of thorough documentation and follow-up care as per the physician's orders. The resident's care plan was not updated to reflect the burn or the treatment orders, and there were multiple instances where wound care treatments were not documented as completed. The resident's condition worsened over several days, with the burn developing blisters and requiring further medical intervention. Despite the physician's orders for wound care, the facility staff failed to consistently document the completion of these treatments or provide reasons for their omission. The resident was eventually sent to the hospital for further evaluation and treatment, where it was determined that the burn had progressed to a second-degree burn involving less than 10% of the body surface. The resident required a skin graft due to the severity of the burn. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing and other staff members acknowledged the absence of necessary documentation, including incident reports and nurses' notes, which should have been completed following the incident. The failure to adhere to the facility's policies on wound management and comprehensive care planning contributed to the deficiency in care provided to the resident.
Failure to Prevent Medication Errors Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, leading to a hospitalization due to a benzodiazepine overdose for one resident. The resident, who was cognitively intact and required substantial assistance for mobility, was on multiple medications, including those with Black Box Warnings. The facility did not properly document or monitor the side effects of these medications, nor did they follow physician orders to discontinue Xanax once Valium was started. This oversight resulted in the coadministration of Xanax and Valium, which contributed to the resident's altered mental status and subsequent hospitalization. The facility's policies required that physician orders be clearly documented and monitored for adverse effects, especially for psychotropic medications. However, the staff failed to adhere to these policies. The resident's medication orders were not properly reviewed or entered into the electronic medical record, and system-generated warnings about drug interactions were ignored. The staff did not notify the physician or management about the medication errors, and there was a lack of documentation regarding the resident's condition and behavior leading up to the hospitalization. Interviews with facility staff revealed a lack of communication and understanding of the procedures for handling medication orders and monitoring for adverse effects. The DON and other staff members were unaware of the medication errors until the resident's condition deteriorated significantly. The resident's physician and psychiatrist were not informed of the errors, and the facility's failure to address the warnings and interactions contributed to the resident's overdose and hospitalization.
Facility Fails to Meet QAA Meeting Attendance Requirements
Penalty
Summary
The facility failed to meet the required minimum of six staff members attending the Quality Assessment and Assurance (QAA) meetings, as mandated by their Quality Assurance Process Improvement (QAPI) policy. The policy outlines that the interdisciplinary team should meet at least quarterly, with best practice being monthly meetings, and should include representatives from all departments, as well as input from residents and frontline care staff. However, a review of the facility's QAA minutes log for 2024 revealed that the meetings consistently had only four attendees: the Administrator, the Director of Nursing (DON), the Infection Preventionist (IP), and the Medical Director. On two occasions, the Medical Director was absent, reducing the number of attendees to three. During an interview, the Administrator acknowledged that the QAA members included the Administrator, the DON, the MDS Coordinator, the Medical Director at least quarterly, and most department heads. However, the Administrator was unaware of the requirement for a minimum number of staff to attend the QAA meetings. This lack of awareness and adherence to the policy resulted in the facility's failure to have the required number of staff members present at the QAA meetings, which is a deficiency in maintaining the standards set by their QAPI policy.
Failure to Document and Assess Bed Rail Use
Penalty
Summary
The facility failed to properly document and assess the use of bed rails for several residents, leading to potential safety risks. For Resident #2, the facility did not conduct ongoing evaluations of the bed rails, which were found to be loose and had been reported by the resident as a safety concern. Despite the resident's repeated complaints and the acknowledgment by staff that the bed rails were loose, there was no documented maintenance request or follow-up to ensure the bed rails were secure. Additionally, the facility did not document the identification and use of possible alternatives to bed rails, nor did they obtain informed consent for their use. For Resident #12, the facility did not document any assessment of the risks versus benefits of using side rails, nor did they obtain informed consent or include the use of side rails in the resident's care plan. Observations showed that the resident had side rails in use, but there was no documentation of an order for their use or any assessment to ensure they were appropriate and safe. Similarly, for Resident #93, the facility failed to document the use of possible alternatives, assess the risks versus benefits, obtain informed consent, or include the use of side rails in the care plan, despite the presence of side rails in the resident's room. Interviews with staff revealed a lack of clarity and responsibility regarding the assessment and maintenance of bed rails. Maintenance staff were not aware of the need for regular safety checks, and there was confusion among nursing staff about who was responsible for assessing and documenting the use of bed rails. The facility's procedures for bed rail safety checks and device care planning were not followed, leading to deficiencies in ensuring the safety and appropriateness of bed rail use for residents.
Failure to Assess and Monitor Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents only self-administer their medication after being assessed by an interdisciplinary team and if clinically indicated. This deficiency was observed when a resident, who had not been assessed for self-administration, was found with medications left on their bedside table. The facility's policy requires an assessment of the resident's cognitive, physical, and visual ability to self-administer medications, which was not conducted for this resident. Additionally, the resident's care plan did not include any provisions for self-administration or bedside medication storage. Observations revealed that the resident had multiple instances of medications left on their bedside table, including empty medication cups and loose tablets. Interviews with staff and other residents indicated a pattern where medications were left at the bedside for residents to take at their discretion, contrary to the facility's policy. Staff members, including CNAs, CMTs, and LPNs, acknowledged finding loose medications in resident rooms and reported that medications should not be left at the bedside without a physician's order. The Director of Nursing and the Administrator confirmed that no residents in the facility had orders to self-administer medications or keep medications at the bedside, except for creams. They emphasized that staff should stay with residents during medication administration and that any loose medications found should be reported and identified. Despite these protocols, the facility did not adhere to its policy, resulting in the deficiency observed by the surveyors.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents when their Medicare-covered services were ending. For one resident, the facility did not issue the NOMNC when all covered Medicare services ended. For another resident, the facility provided a blank SNFABN form with writing indicating notification to the guardian, but it lacked dates and signatures. Additionally, the NOMNC was provided without a date or signature from the resident or representative. Interviews with facility staff revealed that the Social Service Designee was new and had not completed any of these notices, indicating a lack of training or oversight in this area. The Administrator acknowledged that the beneficiary notifications should have been provided as required but was unaware that these notices were not completed. The facility did not have a policy regarding the issuance of these notices, contributing to the deficiency.
Failure to Maintain Level II PASRR Documentation
Penalty
Summary
The facility failed to coordinate with the appropriate state-designated authority to ensure that individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs. Specifically, the facility did not obtain and maintain a copy of a Level II Pre-Admission Screening and Resident Review (PASRR) for a resident with multiple diagnoses, including anoxic brain damage, cognitive communication deficit, anxiety, bipolar disorder, schizoaffective disorder, and major depressive disorder. The resident was admitted to the facility without the necessary Level II PASRR documentation, which was indicated and due shortly after the Level I PASRR was completed. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and maintenance of PASRR documentation. The Social Services Director was unable to locate the Level II PASRR and believed it had been completed by a previous director. The Director of Nursing indicated that PASRRs are typically completed by the admissions nurse, who was no longer employed at the facility. The Administrator confirmed that all residents must have a completed Level I PASRR prior to admission and that Level II PASRRs, when indicated, should be completed and included in the resident's electronic medical record. This oversight highlights a breakdown in the facility's process for ensuring compliance with PASRR requirements.
Failure to Obtain Order and Care Plan for Brace Use
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not obtaining an order for, care planning, and monitoring the use of a brace for a resident. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, foot drop, and left ankle contracture, used an ankle foot orthotic (AFO) brace for mobility. Despite the resident's need for the brace, the facility did not have a physician's order for its application or monitoring, nor was it adequately included in the resident's care plan. Observations and interviews revealed that the resident consistently wore the brace while in a wheelchair, and staff were aware of its use. However, there was a lack of documentation in the resident's physical therapy and nursing progress notes regarding the brace. Interviews with various staff members, including a Certified Occupational Therapist Assistant, Physical Therapy Assistant, Certified Nurse Assistants, Registered Nurse, Licensed Practical Nurse, MDS Coordinator, Assistant Director of Nursing, Director of Nursing, and the Administrator, confirmed that there was no formal order or care plan for the brace, and staff were unclear about the protocols for its application and monitoring. The deficiency was further highlighted by the fact that staff assumed the brace should be applied when the resident was out of bed and removed when in bed, but there was no official guidance or documentation to support this practice. The lack of a formal order and care plan for the brace use and monitoring led to inconsistencies in care and potential oversight in monitoring the resident's skin condition under the brace, as noted by the Director of Nursing and other staff members.
Failure to Complete Discharge Summary for Planned Discharge
Penalty
Summary
The facility failed to initiate a discharge summary for a planned discharge of a resident, which is a requirement according to their policy. The resident, who had diagnoses including paraplegia, obesity, spina bifida, and lymphedema, was planning to discharge home with home health services and wound care management. Despite the resident's anticipated discharge being documented in the Minimum Data Set and the physician order sheet, the facility did not complete the necessary discharge summary or document progress notes related to the discharge. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, confirmed that discharges should be documented in the progress notes and discharge summaries should be completed. However, the resident's record showed that these steps were not taken, indicating a lapse in following the facility's discharge policy. This oversight was identified during a review of the resident's records, which revealed the absence of a completed discharge summary and related documentation.
Failure to Provide Adequate Bathing and Hygiene for Resident
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene for a resident who was dependent on staff for bathing. The resident, who had moderate cognitive impairment and was dependent on staff for personal hygiene, bathing, and toileting, was observed with unbrushed, oily hair and a hospital gown with brown stains around the collar. The resident reported having been offered only one shower since admission, despite the facility's policy requiring residents to be offered two showers per week. The facility's records showed a lack of documentation for bathing attempts or refusals, and there was no care plan addressing the resident's need for assistance with bathing or any history of refusal. Interviews with facility staff, including a CNA, LPN, DON, and the Administrator, revealed inconsistencies in the documentation and communication regarding the resident's bathing schedule and preferences. Staff acknowledged that refusals should be documented and that a bed bath should be offered if the resident refused to get out of bed. However, there was a lack of documentation for shower refusals, and the resident's preference for shower days and times was not specified in the electronic medical record. The DON and Administrator confirmed that residents should receive two showers a week, and any refusals should be documented and care planned, which was not done in this case.
Failure to Prevent Burn Injury from Coffee Spill
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by an incident involving a resident who suffered burns from a coffee spill. The incident occurred when the resident, who had a history of seizures and cognitive impairments, spilled hot coffee on their lap, resulting in burns to the left thigh. The resident believed a mild seizure caused the spill, but the facility did not complete a timely investigation or update the resident's care plan with new interventions to prevent future burns. The facility's policy on accident and incident documentation and investigation was not followed. The licensed nurse on duty at the time of the incident did not complete an incident report or document the incident in the resident's medical record as required. Additionally, the Director of Nursing (DON) only added an incident report after being prompted by the Department of Health and Senior Services (DHSS) staff, indicating a delay in addressing the incident. The resident's care plan was not updated with new interventions to prevent future burns until several weeks after the incident. Interviews with facility staff revealed a lack of consistent procedures for monitoring and assisting residents with hot beverages. Staff members indicated that residents often helped themselves to coffee from a dispenser in the dining room, and there was confusion about whether lids were consistently used on hot drinks. The Dietary Manager and other staff acknowledged that residents were not always supervised when obtaining coffee, and there was no clear policy on monitoring the temperature of hot beverages. This lack of supervision and failure to implement timely interventions contributed to the resident's injury and the facility's deficiency in maintaining a safe environment.
Deficiency in Catheter Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of catheter use for a resident, leading to a deficiency in care. The resident, who was cognitively intact and required assistance with daily activities, was admitted to the hospital due to seizure activity and returned with an indwelling Foley catheter. However, the facility did not obtain a physician's order for the catheter's use, nor did they document the medical necessity for its placement. The resident's care plan was not updated in a timely manner to reflect the presence of the catheter. Staff failed to consistently document catheter care and output monitoring as ordered. Specific instances of non-compliance included missing documentation of catheter care on several dates and failure to record catheter output on certain shifts. Interviews with facility staff, including CNAs, LPNs, and RNs, revealed a lack of clarity and consistency in following protocols for catheter management, including obtaining necessary orders and updating care plans. The facility's policy on catheter care was not adhered to, as evidenced by the lack of timely orders and documentation. The resident's catheter was initially placed due to urine retention, but this was not clearly communicated or documented in the facility's records. The deficiency highlights a breakdown in communication and documentation processes within the facility, impacting the quality of care provided to the resident.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with standards of practice and residents' care plans for two residents. For Resident #12, the facility did not include the use of oxygen in the care plan, despite the resident being at risk for impaired gas exchange and shortness of breath. The resident had physician orders for oxygen administration and changing the humidifier bottle weekly, but staff failed to document these changes on several occasions. Observations showed that the resident's oxygen equipment was not dated appropriately, indicating a lack of adherence to the prescribed schedule. Resident #83 also experienced deficiencies in respiratory care. The resident's care plan included oxygen therapy related to congestive heart failure, but staff did not document the required weekly change of oxygen tubing on one occasion. Observations revealed that the oxygen tubing and humidifier were not dated correctly, suggesting that the facility did not follow the physician's orders for equipment maintenance. Interviews with facility staff, including CNAs, RNs, LPNs, and administrative personnel, confirmed that there was an expectation for weekly changes and dating of oxygen equipment. However, the lack of documentation and improper dating of equipment indicated a failure to meet these expectations. The facility's policy on oxygen administration did not address the care of oxygen concentrators, humidifiers, or tubing, contributing to the oversight in maintaining proper respiratory care for the residents.
Incomplete Documentation of Resident Burn Incident
Penalty
Summary
The facility failed to maintain complete medical records for a resident who suffered a burn from spilled coffee. The incident occurred on 12/19/24, but there was no documentation of the burn's assessment or investigation into its cause until the resident was sent to the hospital on 12/23/24. The facility's policy requires that accidents and incidents be documented in the electronic health record, but this was not done in this case. The resident, who was cognitively intact, had a burn on the left thigh and lower leg. The resident believed a seizure caused the coffee spill. The initial assessment by a registered nurse noted a reddish, pink area with some shriveled skin, but no measurements or detailed documentation were made. The resident was eventually sent to the hospital for further evaluation and treatment, where the burn was debrided and dressed. Interviews with facility staff, including the RN, LPN, ADON, and DON, revealed that the burn should have been assessed, measured, and documented in the resident's medical record. The lack of documentation and investigation into the incident was acknowledged by the staff, indicating a failure to adhere to the facility's policy on accident and incident documentation.
Failure to Maintain Working Call Light System
Penalty
Summary
The facility failed to maintain a working call light system for two residents sharing a room, affecting their ability to request assistance. The call light system in the room was malfunctioning, with the indicator light above the door continuously blinking and not alerting the nurses' station. This issue persisted for several weeks, during which the residents were provided with bells to use as an alternative means of communication. Resident #34, who has moderate cognitive impairment and requires supervision with transfers and toileting, reported that the call light had not been working for weeks. Similarly, Resident #91, also with moderate cognitive impairment and requiring supervision, confirmed the call light had been malfunctioning for at least two weeks. Both residents relied on bells to summon help, as the call light system was ineffective. Interviews with staff, including CNAs, RNs, and the ADON, revealed a lack of awareness and communication regarding the malfunctioning call light system. Although some staff believed maintenance was informed, the Maintenance Supervisor was unaware of the issue due to the absence of a work order. The Administrator mistakenly thought the problem had been resolved, highlighting a breakdown in communication and follow-up within the facility.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that prior survey results were kept current and complete in a readily accessible, public location for residents, family members, and residents' legal representatives. During an observation, a maroon binder was found in a wall pocket near the television/day area at the junction of the 100, 200, and 300 halls. This binder contained the most recent survey results from May 2024 but did not include results from the previous three years, including the last recertification survey completed in February 2023. Interviews with residents during a council group meeting revealed that they were unaware of where to find survey results, indicating a lack of communication and accessibility. Further interviews with staff, including a CNA, RN, LPNs, the DON, and the Administrator, showed a general lack of knowledge about the exact location of the survey results. While some staff believed the results were at the nurses' station or near the Administrator's office, none could locate them. The Administrator acknowledged that it was his responsibility to ensure the binder was up to date with the most recent results of complaints and surveys, but he was unaware that the previous annual survey results were missing from the binder.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information in a prominent place readily accessible to residents and visitors on a daily basis, as mandated by federal and state agencies. The facility's policy, updated on 02/28/23, requires the daily posting of direct care staffing hours, including actual and total hours worked. The responsibility for this task falls on the Staffing Coordinator, nursing staff, nursing administration, the Director of Nursing (DON), and the Administrator. However, during a resident council group meeting, most residents reported being unaware of where staffing levels were posted, and one resident noted that the daily staffing sheet was often outdated or missing. Observations from 02/06/25 to 02/11/25 revealed that the daily staffing sheet was not updated daily and was sometimes missing entirely. Interviews with the DON and the Administrator indicated a lack of awareness regarding the failure to post and update the staffing sheet daily. The DON mentioned that the charge nurses sometimes posted the sheets, and the Assistant Director of Nursing (ADON) had been overseeing the task, but the facility had been without an ADON for some time. The Administrator confirmed that the only location for the staffing sheet was near the front television area, and he was unaware of the lapses in posting.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written discharge notice, including the reason for discharge and the right to appeal, to a resident who was not allowed to return to the facility after hospitalization. The resident, who had multiple diagnoses including paraplegia, bipolar disorder, type II diabetes, dysphagia, cognitive communication deficit, and schizophrenia, was admitted to the facility and had an active discharge plan to the community. However, after a series of behavioral incidents and hospitalizations, the facility did not issue a written discharge notice when the resident was not accepted back. The resident exhibited behaviors such as rapid speech, restlessness, agitation, and refusal to follow medication protocols, leading to multiple hospital visits. On one occasion, the resident was sent to the hospital for a psychiatric evaluation and placed on a 96-hour hold. Despite these events, the facility did not document or provide a written discharge notice to the resident or a representative, as required by regulations. Interviews with facility staff revealed a lack of clarity and adherence to the facility's policy regarding emergency discharges. The Social Service Director and other staff members acknowledged the absence of a written discharge notice and were unsure of the facility's procedures for such situations. The facility's failure to provide the necessary documentation and notification constitutes a deficiency in meeting regulatory requirements for resident discharge procedures.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, resulting in delayed responses to call lights and inadequate care for several residents. Observations and interviews revealed that call lights were not answered in a timely manner, with some residents waiting for extended periods for assistance. For instance, one resident reported being left in a wet brief for four hours, while another resident had to wait from 9:00 P.M. to 2:00 A.M. for help after activating the call light. These delays were attributed to insufficient staffing levels, particularly on the 100, 200, and 300 halls, which were described as the heaviest halls. The facility's staffing sheet indicated that during the day shift, there were only two CNAs covering the 100, 200, and 300 halls, and one CNA each for the 400, 500, and 600 halls. At night, the staffing was even more limited, with only one CNA covering the 100, 200, and 300 halls after 11:00 P.M. Interviews with staff members confirmed that the facility was understaffed, with aides often having to cover multiple halls or leave their assigned areas to assist elsewhere. This understaffing led to prolonged wait times for residents needing assistance with activities of daily living, such as toileting and changing soiled briefs. Residents expressed dissatisfaction with the response times, and staff members acknowledged the challenges posed by the staffing shortages. The Director of Nursing and the Administrator both stated expectations for call lights to be answered within 5 to 10 minutes, but the reality was that residents often experienced much longer wait times. The lack of a policy regarding answering call lights further compounded the issue, as there was no formal guideline to ensure prompt responses to residents' needs.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving a Licensed Practical Nurse (LPN) and a resident. The LPN raised their voice and used inappropriate language towards the resident after the resident experienced a fall. The resident, who had a history of falls and moderate cognitive impairment, was attempting to go outside to smoke when the incident occurred. The LPN's actions were contrary to the facility's policy on resident rights, which mandates that staff treat residents with kindness, respect, and dignity. The incident began when the resident, who was unsteady on their feet, was being escorted by a Certified Nurse's Aide (CNA) to the smoking area. The resident tripped over a table and fell, despite the CNA's attempt to prevent the fall. After assisting the resident off the floor, the LPN told the resident that they needed to stay on their feet if they wanted to smoke. Witnesses reported that the LPN used profanity and yelled at the resident, expressing frustration over the resident's repeated falls and the associated paperwork. Interviews with other staff members, including Certified Medication Technicians (CMTs) and CNAs, confirmed that the LPN's behavior was inappropriate and not in line with the facility's standards for treating residents. Staff members acknowledged that cursing at a resident is unacceptable and should be reported to supervisory personnel, such as the Director of Nursing (DON) or the Administrator. The facility's policy requires that any concerns related to the treatment of residents by staff be reported to the appropriate authorities.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure a fully functional call light system for all residents, as evidenced by malfunctioning call lights for two residents. Resident #2, who has moderate cognitive impairment and requires substantial assistance with activities of daily living, reported being left in a wet brief for four hours due to a non-functioning call light. The resident's call light was observed to be on outside the room, but it was not showing at the nurses' station, leading to a delay in care. The resident also mentioned that the backup bell was out of reach, further complicating the situation. Resident #4, who also has moderate cognitive impairment and requires assistance with toileting, reported that the bathroom call light did not light up outside the room, although it did sound at the nurses' station. This malfunction resulted in the resident being left on the toilet for an extended period without assistance. Observations confirmed that the call light in the bathroom did not light up outside the room, corroborating the resident's account of the issue. Interviews with various staff members, including CNAs, RNs, and the Administrator, revealed that there were known issues with the call light system, affecting its functionality at times. Staff reported that some call lights did not function consistently, either not sounding at the nurses' station or not lighting up in the hall. Despite the presence of backup bells, the malfunctioning call lights led to delays in responding to residents' needs, highlighting a deficiency in the facility's call light system.
Failure to Report Alleged Verbal Abuse by CNA
Penalty
Summary
The facility failed to report an anonymous allegation of possible verbal and mental abuse by a staff member, CNA A, to the State Survey Agency (DHSS) within the required two-hour timeframe. The facility's protocol mandates that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made. Despite receiving a report from the corporate office about CNA A's inappropriate behavior, including smoking a weed pen on duty and verbally abusing residents, the facility did not report this to DHSS. Interviews with various staff members, including the DON and the Administrator, confirmed that the allegations were not reported as required. The facility's investigation into the allegations involved interviews with seven residents, with one resident describing the CNA as "goofy" and another mentioning comments about smoking. The DON suspended CNA A pending the investigation but was unsure if the Administrator reported the allegations to DHSS. The Administrator believed he had two hours to investigate whether abuse occurred and concluded that the facility's investigation showed no abuse, thus not reporting the allegations to DHSS. This failure to report constitutes a deficiency in adhering to the mandated reporting protocol.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The deficiency involves a failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. This includes the provision of treatment and supports for daily living in a safe manner. The report references event ID JJ94112, which details the specific citation related to this deficiency. The deficiency is identified under the codes MO00240384 and MO00240390, indicating specific instances where the facility did not meet the required standards for maintaining a safe and homelike environment for its residents.
Failure to Develop Timely Care Plan
Penalty
Summary
The deficiency involves the failure to develop a complete care plan within 7 days of the comprehensive assessment. This care plan was not prepared, reviewed, and revised by a team of health professionals as required. The report references event ID JJ94112 for further citation details, indicating a specific instance where this requirement was not met.
Failure to Assist Residents with Daily Living Activities
Penalty
Summary
The deficiency involves the failure to provide care and assistance for activities of daily living to residents who are unable to perform these tasks independently. This issue was identified during a survey, as indicated by the event ID JJ94112. The report references specific cases, MO00240384 and MO00240390, where residents did not receive the necessary support for their daily living activities, which is a critical aspect of their care.
Failure to Maintain a Safe Environment
Penalty
Summary
The deficiency involves the failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. This was identified during a survey with event ID JJ94112, which cited the facility under codes MO00239914 and MO00240161. The report highlights that the facility did not maintain a safe environment, which could potentially lead to accidents, although specific incidents or resident details are not provided in the report.
Inadequate Infection Control Program
Penalty
Summary
The report identifies a deficiency related to the implementation of an infection prevention and control program. The facility failed to establish and maintain an effective program to prevent and control infections, as required by regulations. This deficiency was noted during a survey event, identified by event ID JJ94112, which highlighted lapses in the facility's infection control practices. The specific details of the actions or inactions leading to this deficiency are not provided in the report.
Failure to Properly Document and Destroy Discontinued Medications
Penalty
Summary
The facility failed to maintain an ongoing monitoring process for the accurate documentation and accountability of expired or unusable medications. This deficiency was observed through the presence of a large quantity of discontinued medications, including controlled substances, that were not destroyed in a timely manner. The medications were found in various locations, such as on the counter in the medication room and in a green storage tote, as well as in a drawer in the Director of Nursing's (DON) office. The facility's policy required that discontinued medications be destroyed promptly, yet observations revealed that there were approximately 200 to 300 pills on the counter and 600 to 700 pills in the tote awaiting destruction. Interviews with staff, including Registered Nurses (RNs) and the DON, highlighted a lack of clarity and adherence to the facility's policies regarding the destruction of medications. RN A mentioned that medications were destroyed when extra staff were available, but was unaware of the specific timeframe required for destruction. The DON confirmed that controlled substances were kept in a locked drawer in their office and acknowledged the unacceptable number of discontinued medications on hand. Additionally, the facility was unable to provide a logbook documenting the destruction of controlled substances, further indicating a lapse in proper record-keeping and accountability. The deficiency involved eleven residents, with medications belonging to both current and former residents found in the DON's office and the medication room. These included medications such as clonazepam, lorazepam, morphine, and others, some of which were expired or lacked the necessary controlled substance accountability sheets. The facility's failure to develop and implement a policy for the proper documentation, destruction, and disposal of medications contributed to the accumulation of these medications, posing potential risks to resident safety and regulatory compliance.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by the inadequate and untimely cleaning of the floor in a resident's room and the failure to change soiled bedding for one resident. This deficiency was identified through observation, interview, and record review. The facility had a census of 110 residents at the time of the survey.
Failure to Update Resident Care Plan Post-Hospitalization
Penalty
Summary
The facility failed to maintain a comprehensive person-centered care plan for all residents. Specifically, the staff did not update the care plan for one resident to include new information on effective communication after the resident returned from the hospital. Additionally, the facility did not ensure that all staff members were aware of this change. The facility's census at the time was 110.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide necessary services for dependent residents to maintain grooming and personal hygiene. This deficiency was identified when staff did not routinely attempt to change urine-soaked clothing and complete bathing and/or showering for a resident. The facility had a census of 110 residents at the time of the survey.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure an environment as free from accident hazards as possible by not placing the call light within reach of a resident, as was care planned for fall intervention. This deficiency was identified through observation, interview, and record review. The facility had a census of 110 residents at the time of the survey.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by several lapses in protocol. Staff did not clean urine from a resident's floor in a timely manner, resulting in the urine being stepped in and tracked through the facility without cleaning the shoes. Additionally, a resident was left with bare feet in a urine puddle. Furthermore, staff failed to clean a blood pressure monitor after it made contact with the floor before using it on the same resident. These actions and inactions contributed to the deficiency observed during the survey.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, specifically in the case of one resident who was observed to have a room in unsanitary conditions. The resident, who has moderate cognitive impairment and is frequently incontinent, was found in a room with a floor covered in dried yellow liquid and papers stuck to it, along with what appeared to be human feces under the bed. The resident's bed was also in poor condition, with dirt, debris, and large wet spots that smelled of urine. Interviews with staff revealed that there was confusion and inconsistency regarding the responsibilities for cleaning the resident's room. Housekeeping was short-staffed, and nursing staff were expected to clean the rooms, including changing soiled bedding and cleaning up bodily fluids. However, there was a lack of clarity and accountability, as some staff believed that housekeeping was responsible for certain tasks, while others indicated that nursing staff should handle them. The facility's policies on room cleaning procedures and cleaning detail forms were not followed, leading to the unsanitary conditions observed. Staff interviews highlighted issues with staffing shortages and miscommunication about cleaning responsibilities, contributing to the failure to provide a safe and clean environment for the resident. Despite the resident's cognitive impairment, there was no evidence that the resident resisted having their bedding changed, contradicting some staff claims.
Failure to Update Resident Care Plan with New Communication Needs
Penalty
Summary
The facility failed to maintain a comprehensive person-centered care plan for a resident who returned from the hospital with new communication needs. The resident, who had severe cognitive impairment and was hard of hearing, was readmitted to the facility after a hospital stay where it was determined that writing questions on paper was the most effective way to communicate with them. Despite this, the resident's care plan was not updated to include this new information, and the staff was not adequately informed of the change. The facility's policy requires that care plans be updated upon a change in condition, but this was not done for the resident in question. The MDS Coordinator, who is responsible for updating care plans, did not incorporate the hospital's recommendations into the resident's care plan. Additionally, the Kardex report, which is used by staff to understand residents' daily care needs, was outdated and did not reflect the resident's current hearing difficulties. Interviews with various staff members, including the Admission Coordinator, MDS Coordinator, CNAs, and the Director of Nursing, revealed a lack of communication and coordination in updating the care plan. The staff was aware of the resident's hearing issues but continued to rely on outdated methods of communication. The failure to update the care plan and inform all staff of the new communication strategy led to a deficiency in providing person-centered care for the resident.
Failure to Maintain Resident Hygiene and Dignity
Penalty
Summary
The facility failed to provide necessary services for a resident to maintain grooming and personal hygiene, as staff did not complete routine attempts to change urine-soaked clothing and ensure regular bathing or showering. The resident, who had severe cognitive impairment and was diagnosed with unspecified intracranial injury, muscle weakness, and anxiety disorder, required partial to moderate assistance with activities of daily living (ADLs) such as toileting, dressing, and personal hygiene. Despite the resident's care plan indicating the need for supervision and assistance with these tasks, staff did not consistently follow through with the required care. Observations revealed that the resident was often seen in urine-soaked clothing, with no attempts made by staff to assist in changing or bathing the resident. The resident was noted to refuse showers on multiple occasions, with staff documenting reasons such as combativeness and yelling. However, there was a lack of documentation regarding attempts to re-approach the resident or any successful interventions to address the hygiene issues. Interviews with staff indicated that there was no consistent method for CNAs to document care provided, and communication about the resident's needs was often relayed verbally or through informal means such as text messaging. The facility's policy required staff to document all shower refusals and re-approach attempts, but this was not consistently done. The resident's care plan emphasized the importance of providing cues and negotiating times for ADLs to encourage participation, yet these strategies were not effectively implemented. The lack of proper documentation and follow-up on the resident's hygiene needs contributed to the deficiency, as staff failed to ensure the resident's dignity and cleanliness were maintained.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure an environment as free from accident hazards as possible by not placing the call light within reach of a resident, as outlined in the care plan for fall prevention. The resident, who had multiple diagnoses including schizophrenia, COPD, and epilepsy, was observed in a wheelchair with a strong odor of urine in the room and liquid dripping from the wheelchair seat. The call light was attached to the bed, out of reach, while the resident was across the room in the wheelchair. Throughout the observation period, various staff members, including the Director of Nursing (DON), Certified Nurse Aide (CNA) A, Registered Nurse (RN) B, and Licensed Practical Nurse (LPN) C, entered and exited the room without ensuring the call light was within the resident's reach. The resident was noted to be lethargic and was eventually assessed for signs of congestive heart failure exacerbation. Despite the presence of staff and emergency medical services, the call light remained on the floor and out of reach until later in the observation period. Interviews with staff, including CNA A, CNA D, LPN C, RN B, and the DON, confirmed that call lights should always be within reach of residents. The DON acknowledged observing the call light on the floor earlier and stated that staff should check call lights during rounds every two hours. The facility did not provide a policy regarding call light accessibility, contributing to the deficiency in ensuring a safe environment for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to ensure that residents were free from significant medication errors due to a lack of a system to accurately document the timely administration of medications. The staff frequently documented two doses of medications administered at or near the same time and outside of scheduled time frames for a resident. The facility did not have a policy related to a liberalized medication administration system, nor did it train nursing staff on such a system. This resulted in multiple instances where medications were not administered according to the prescribed schedule. The resident involved had multiple diagnoses, including metabolic encephalopathy, exocrine pancreatic insufficiency, anxiety disorder, bipolar disorder, and chronic pain syndrome. The resident's care plan required the administration of antipsychotic, analgesic, and other medications as ordered by the physician, with monitoring for side effects and effectiveness. However, the medication administration audit reports revealed numerous discrepancies in the timing of medication administration, with doses being given hours after the scheduled time or simultaneously with other doses. Specific medications involved included Creon, oxycodone, diazepam, and gabapentin. For instance, Creon was documented as being administered hours after the scheduled time, and oxycodone doses were often signed out hours before or after the documented administration time. Similarly, diazepam and gabapentin doses were frequently administered at the same time as other doses or significantly delayed. These inconsistencies indicate a failure to adhere to professional standards for medication administration, contributing to the deficiency identified by the surveyors.
Infection Control Deficiency Due to Mishandling of Urine Spill
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by the mishandling of a urine spill involving a resident. The incident began when a strong odor of urine was detected, and a resident was observed sitting in a wheelchair with liquid dripping from the seat, forming a puddle on the floor. Despite the presence of the liquid, the Director of Nursing (DON) and other staff members, including a Certified Nurse Assistant (CNA) and a Registered Nurse (RN), entered and exited the room without addressing the spill or cleaning their shoes after stepping in the urine. The resident's bare feet remained in contact with the urine puddle throughout the incident. The staff's failure to clean the urine promptly and properly was compounded by the mishandling of medical equipment. CNA A dropped a portable blood pressure monitor on the floor near the urine puddle and proceeded to use it on the resident without cleaning it. This oversight was not corrected by RN A, who attempted to obtain the resident's blood pressure without sanitizing the equipment. The facility's policy on cleaning medical equipment after contact with the floor was not followed, contributing to the infection control deficiency. Interviews with staff members revealed a lack of awareness and adherence to infection control protocols. CNA A and LPN C acknowledged the presence of the urine puddle and the need for cleaning, but actions were delayed. RN B and the DON admitted to not noticing the urine or odor initially and failed to clean their shoes after stepping in the urine. The Administrator confirmed that staff should provide incontinent care every two hours and clean medical equipment after floor contact, highlighting the facility's failure to adhere to its own policies and procedures.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple instances of staff not donning appropriate PPE when entering isolation rooms of residents positive for influenza A. Observations showed that staff, including CNAs and a CMT, entered and exited isolation rooms without wearing gloves, gowns, or masks, and did not perform hand hygiene upon exiting. This was despite clear signage and availability of PPE outside the rooms. Interviews with staff revealed a lack of adherence to infection control protocols, with some staff unaware of the isolation status of residents and others admitting to forgetting to don PPE or not following proper procedures for PPE disposal and hand hygiene. Resident #2 and Resident #3 were both on droplet isolation for influenza A, yet staff were observed entering their shared room without PPE and failing to perform hand hygiene. CNA A was seen entering and exiting the room multiple times without donning PPE and handling items such as water cups without washing hands. Similarly, CNA A, NA C, and NA D were observed in the isolation room without PPE. Interviews with these staff members confirmed their non-compliance with infection control protocols. Resident #4 was also on droplet isolation for influenza A, with similar observations of non-compliance. CMT F was seen in the resident's room wearing only a surgical mask and not donning other required PPE. The CMT admitted to not following proper procedures for PPE use and hand hygiene. Interviews with other staff, including an RN, CNA, LPN, and the Infection Control Preventionist, confirmed the expected protocols for PPE use and hand hygiene, which were not being followed. The DON and Administrator acknowledged the deficiencies and the facility's reliance on CDC guidelines without a specific policy for transmission-based precautions related to influenza.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for all residents when staff did not replace or fix the resident room walls and closet ceiling where a black substance was present in one resident's room. The resident required supervision or assistance with most activities of daily living and had a diagnosis of pulmonary disease. Observations revealed black substances on the walls and ceiling in various parts of the resident's room, including around the sprinkler head and between the bathroom and closet. The black substance covered significant areas, indicating a lack of timely maintenance and cleaning. The facility census was 104 at the time of the observation. Interviews with staff, including a CNA, Maintenance Supervisor, Housekeeper, Housekeeping Supervisor, DON, and Administrator, revealed that the black substance had been observed but not adequately addressed. The CNA reported the issue to a nurse, but no further action was taken. The Maintenance Supervisor stated that maintenance is responsible for checking rooms and treating black substances but was unaware of the issue. Housekeeping staff are expected to notify their supervisor of such findings, who then informs maintenance. Despite these protocols, the black substance remained untreated, indicating a breakdown in communication and procedural adherence among the staff.
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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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