St Andrew's At Francis Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Eureka, Missouri.
- Location
- 400 Summerville Blvd, Eureka, Missouri 63025
- CMS Provider Number
- 265195
- Inspections on file
- 22
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at St Andrew's At Francis Place during CMS and state inspections, most recent first.
A CNA failed to honor a resident's right to refuse getting out of bed for a shower, proceeding with a transfer despite the resident's objections. The resident, who was able to communicate their wishes, sustained a significant skin tear during the transfer, requiring hospital treatment. The incident revealed that staff did not consistently respect or understand resident rights, and the facility's investigation focused on transfer technique rather than the violation of self-determination.
A resident did not receive appropriate care or services to maintain or improve range of motion (ROM) and mobility, and the facility did not ensure interventions were in place to prevent decline unless medically unavoidable.
The facility failed to accommodate resident preferences and needs, leading to deficiencies in care. Two residents faced issues with room arrangements that hindered access to personal belongings and wheelchair maneuverability. Additionally, the facility removed siderails from beds without providing alternatives or conducting proper assessments, affecting four residents who relied on them for mobility and repositioning. The facility's policies on adaptive devices were not followed, and there was confusion among staff about assessment responsibilities.
The facility failed to maintain consistent and updated code status documentation for four residents, leading to discrepancies between their wishes and recorded medical directives. The policy requires residents to complete a therapeutic support level/resuscitation plan upon admission, but inconsistencies were found in the EMR and nurse's report sheets. Interviews with staff revealed lapses in verifying and updating code status information, contributing to the deficiency.
The facility failed to maintain cleanliness and food safety standards in the kitchen, with equipment like the stove and fryer found with heavy stains and old grease. Expired milk was also not discarded, as observed over several days. The Dietary and Kitchen Managers acknowledged the lapses in cleaning and food disposal protocols, affecting the facility's 73 residents.
The facility failed to track the required 12 hours of annual education for CNAs and CMTs, as documentation did not include the length of time for completed in-services. The Administrator acknowledged the lack of tracking and inability to confirm if staff received the mandated education.
The facility failed to follow up on TPL forms for a deceased resident, resulting in a deficiency. A resident's account remained open with a balance of $481.39 beyond the 30-day period after death. The Corporate Business Office Manager admitted to not following up with the TPL unit in a timely manner, contrary to the Administrator's expectations.
The facility failed to update care plans for two residents, one with a fall risk and another with a hospice diagnosis. A resident with impaired cognition and multiple diagnoses experienced an unwitnessed fall, but their care plan did not reflect fall risk or interventions. Another resident receiving hospice care had no updates in their care plan to reflect hospice status, despite a physician's order. Interviews confirmed that care plans should be updated following changes in condition.
The facility did not follow physician orders for two residents. One resident, with multiple health issues, had orders for daily and weekly weights, but only one weight was recorded. Another resident, on hospice care, lacked a documented physician's order for hospice, despite it being noted in their care plan. The DON confirmed the need for a physician's order for hospice care.
The facility failed to implement a 14-day stop date for PRN psychotropic medications for two residents with severe cognitive impairments. One resident had an order for Lorazepam without a stop date, while another had an order for Quetiapine for agitation, also lacking a stop date. Staff interviews confirmed the expectation for a 14-day stop date on such medications.
The facility failed to document treatments for a resident's stage four pressure ulcer consistently, with multiple instances of blank entries in the TAR. Additionally, another resident receiving hospice care lacked the required certification of terminal illness form in their records. These deficiencies indicate lapses in documentation practices, which are essential for ensuring proper care and oversight.
The facility failed to follow infection control standards by not ensuring staff wore appropriate PPE for two residents and did not post necessary signage for another resident requiring Enhanced Barrier Precautions (EBP). Staff did not wear gowns while repositioning a resident with an indwelling catheter, and the catheter drain was observed touching the floor without being sanitized. Another resident with a G-tube on EBP was assisted without PPE due to flipped signage. Additionally, a resident with a suprapubic catheter and MDRO lacked visible signage and accessible PPE supplies.
The facility failed to ensure residents received treatment and care according to professional standards, with significant documentation gaps for ordered treatments. A resident with a g-tube and another with a suprapubic catheter did not receive documented care, and similar issues were noted for other residents. Interviews confirmed expectations for staff to follow orders and document treatments, but consistent failures were observed, particularly with evening and agency staff.
A resident, who is cognitively intact and has multiple health conditions, experienced a deficiency in dignity and respect when their preference for female caregivers was not honored. Despite expressing this preference during a care plan meeting, a male CNA assisted the resident with toileting and bedtime routines, leading to distress. The CNA did not respect the resident's wishes regarding personal care routines, resulting in a deficiency finding.
The facility failed to follow its fall policy by not conducting necessary assessments and neurological checks for three residents after falls. A resident returned from the hospital without documented neuro-checks, another had a head injury without consistent documentation, and a third had multiple falls without completed assessments. This led to a deficiency in care.
An LPN at a facility was found to have misappropriated controlled substances, including oxycodone and Ativan, from multiple residents. The facility's policies on controlled substance management and reporting were not effectively enforced, allowing the LPN to remove medications unauthorizedly over several days. The LPN was observed on video taking narcotics and discrepancies were noted in narcotic sign-out sheets.
The facility failed to report the misappropriation of controlled substances by an LPN within the required timeframe, affecting multiple residents. The LPN was found to have diverted medications such as oxycodone and Ativan, with discrepancies noted in narcotic sign-out sheets and video evidence showing the LPN placing narcotics in their pocket. This delay in reporting compromised resident safety.
A facility failed to suspend an LPN during an investigation into alleged misappropriation of controlled substances, allowing the LPN to continue working and misappropriate medications from multiple residents. The facility did not follow its policy of suspending staff pending investigation, resulting in continued medication discrepancies. Additionally, the facility failed to conduct thorough investigations into other incidents, such as missing resident property, and did not report findings to the DHSS within the required timeframe.
A resident with severe cognitive impairment fell while using a walker, and the facility failed to follow a stat x-ray order for the resident's right shoulder and humerus. The incident was not documented, and no investigation was conducted. The RN did not document the fall or follow up on the x-ray order, and the resident was monitored overnight without complaints of pain. The next day, severe pain and swelling were noted, and the x-ray revealed a complex fracture, leading to hospital treatment.
A resident with moderate cognitive impairment and multiple sclerosis fell out of bed during perineal care due to a CNA's lack of awareness of the two-person assistance requirement. The facility's system for accessing care plans via iPhone was not effectively utilized by all staff, resulting in inadequate supervision and care.
Resident's Right to Refuse Care Not Honored, Resulting in Injury
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA), who was an agency staff member, failed to respect a resident's right to self-determination by transferring the resident out of bed for a shower despite the resident's explicit refusal. The resident, who had diagnoses including high blood pressure, arthritis, weakness, and chronic pain, was assessed as having moderate cognitive impairment but was able to make their needs known and communicate effectively. The resident verbally communicated to the CNA that they did not want to get out of bed, but the CNA proceeded with the transfer after being told by a nurse that the resident would be fine once up. During the transfer, the resident resisted, and the CNA used a bear hug technique to move the resident from the bed to the wheelchair. As a result of the transfer, the resident sustained a significant skin tear, approximately ten centimeters long, to the left lower leg, which required hospital treatment and sutures. The incident was witnessed by other staff who noted the CNA appeared verbally agitated, and the resident later described the transfer as rough and feeling like a tussle. The resident expressed being upset about being made to get up and reported pain and ongoing discomfort from the injury. The care plan and medical records confirmed the resident's ability to make choices and the expectation that staff would respect those choices, including the right to refuse care. The facility's investigation into the incident focused primarily on the mechanics of the transfer rather than the violation of the resident's rights. Interviews with staff revealed inconsistent understanding and application of resident rights, with some staff indicating they would follow a nurse's directive even if it contradicted a resident's expressed wishes. The facility's policies and resident handbook emphasized the importance of resident choice and self-determination, but these were not followed in this instance, leading to the resident's rights being disregarded during the event.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve ROM and mobility were not implemented as required.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents, leading to deficiencies in their care. Two residents experienced issues with room arrangements that hindered their ability to access personal belongings and maneuver their wheelchairs. Despite expressing their preferences for bed placement against the wall, the facility staff rearranged the rooms, citing state regulations, which resulted in one resident being unable to reach their nightstand and another struggling to move around due to limited space. The facility did not address these concerns adequately, as staff members were either unaware of the issues or did not take action to resolve them. Additionally, the facility removed all siderails from residents' beds without providing alternative options or conducting proper assessments. Four residents who relied on siderails for mobility and repositioning were affected by this decision. These residents expressed that the siderails helped them feel safer and more independent, yet the facility removed them, citing regulations and corporate decisions. The lack of siderail assessments and the absence of alternative solutions left these residents without necessary support for their mobility needs. The facility's policies and procedures regarding adaptive and assistive devices were not followed, as evidenced by the lack of evaluations and consent for the removal of siderails. The therapy department was not involved in assessing the need for adaptive equipment, and there was confusion among staff about who was responsible for conducting these assessments. The facility's administrator acknowledged the removal of siderails and the ongoing evaluation of their usage, but the residents' care plans were not updated to reflect their needs without siderails, leading to deficiencies in their care.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to maintain consistent and updated code status documentation for four out of 18 sampled residents, leading to discrepancies between the residents' wishes and the recorded medical directives. The facility's policy requires that upon admission, residents or their representatives complete a therapeutic support level/resuscitation plan to ensure timely intervention in emergencies. However, the survey revealed inconsistencies in the documentation of code statuses in the electronic medical records (EMR) and the nurse's report sheets. For Resident #18, there was a conflict between the scanned DNR form and the TSL/Resuscitation Plan, which indicated a full code status. Similarly, Resident #14's records showed a discrepancy between the TSL form indicating full code and the advanced directive tab showing a DNR. Resident #17 and Resident #62 had outdated TSL/resuscitation plans, which had not been updated as required by the facility's policy. These inconsistencies suggest a failure in the process of verifying and updating code status information during admission and annually thereafter. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, highlighted that the responsibility for obtaining and updating code status information lies with the nurses and clinical support staff. The DON acknowledged the need for immediate updates to Resident #18's code status, while the Administrator emphasized the expectation for staff to update code statuses annually and upon any changes requested by residents or their representatives. These lapses in documentation and adherence to policy contributed to the deficiency identified by the surveyors.
Deficiencies in Kitchen Cleanliness and Food Safety
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in the kitchen, as observed over a period of five out of six days. The kitchen equipment, including the stove, steamer, flat grill, and deep fryer, were found with heavy caked-on stains and old grease, indicating a lack of regular cleaning. The cleaning schedules reviewed showed inconsistencies, with some equipment not listed or not initialed as cleaned on certain days. This lack of adherence to cleaning protocols was confirmed during interviews with the Dietary Manager and Kitchen Manager, who acknowledged the expectation for daily general cleaning and a rotational cleaning schedule for certain items. Additionally, the facility failed to discard expired thickened milk, which was observed in the cooler on multiple occasions. The expired milk cartons were not properly labeled or removed, as confirmed by the Dietary Manager, who stated that all items should be labeled, dated, and expired items discarded. The Kitchen Manager also noted that everyone is responsible for ensuring proper labeling and disposal of expired food. These deficiencies in food safety and cleanliness had the potential to affect all residents consuming food from the facility kitchen, given the facility's census of 73 residents.
Deficiency in Tracking CNA and CMT Education Hours
Penalty
Summary
The facility failed to ensure a system was in place to track the required 12 hours of annual education for Certified Nurse Aides (CNAs) and Certified Medication Technicians (CMTs). The review of employee files for six CNAs and four CMTs revealed that while in-services were completed, the documentation did not include the length of time the training was provided. This lack of documentation made it impossible to verify if the staff received the mandated 12 hours of education. During an interview, the Administrator acknowledged that the facility did not track the time for the in-services and could not confirm whether the CNAs or CMTs had received the required education. The Administrator expressed an expectation that staff should have the required education and that the hours should be tracked, indicating a gap between the facility's expectations and its practices.
Failure to Follow Up on TPL Forms for Deceased Resident
Penalty
Summary
The facility failed to ensure timely follow-up on third party liability (TPL) forms for the final accounting of a resident who expired, resulting in a deficiency. This issue affected one of five residents who had money in their resident trust account at the time of death. Specifically, the resident had a balance of $481.39 in their account, and although the TPL form was completed, the account remained open with the same balance beyond the 30-day period. The Corporate Business Office Manager acknowledged the delay in following up with the TPL unit to close the account and admitted that she should have acted sooner. The Administrator expected the TPL form to be submitted within 30 days and follow-up to ensure a zero balance in the resident's account, which was not met in this case.
Failure to Update Care Plans for Fall Risk and Hospice Status
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in addressing their current health needs. Resident #26, who has moderately impaired cognition and multiple diagnoses including cancer and paraplegia, experienced an unwitnessed fall in their room. Despite the facility's policy requiring immediate updates to care plans following a fall, the care plan for Resident #26 did not reflect their fall risk or include interventions to prevent future falls. This oversight indicates a failure to adhere to the facility's Fall Risk Reduction policy, which mandates updating the care plan and implementing interventions after a fall. Resident #56, who was admitted to the facility with moderate cognitive impairment and a prognosis indicating a life expectancy of less than six months, was receiving hospice care. However, the care plan was not updated to reflect the resident's hospice status, goals, or interventions, despite a physician's order for a hospice consult. Interviews with the MDS Coordinator and the Administrator confirmed that care plans should be updated following changes in a resident's condition, such as a fall or a new hospice diagnosis, to ensure CNAs have accurate information to provide appropriate care.
Failure to Follow Physician Orders for Weights and Hospice Care
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following physician orders for two residents. For one resident, the facility did not record daily and weekly weights as ordered by the physician. The resident, who had diagnoses including anemia, malnutrition, hypertension, heart disease, and heart failure, had a physician order for daily weights every Tuesday and weekly weights, but only one weight was recorded. This oversight was acknowledged by the Administrator and Director of Nursing during an interview. For another resident, the facility did not obtain a physician's order for hospice care, despite the resident being on hospice care as indicated in their care plan. The resident had severe cognitive impairment and multiple diagnoses, including anemia, heart failure, and Alzheimer's disease. The care plan noted the resident was receiving palliative care directed by a hospice interdisciplinary team, but the medical records lacked a documented physician's order for hospice care. The Director of Nursing confirmed that there should have been a physician's order for hospice care.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to implement a 14-day stop date for the PRN use of psychotropic medications or provide a rationale for the continued use of the medication for two residents. Resident #18, who was readmitted with severe cognitive impairment and diagnoses including Alzheimer's disease, stroke, anxiety, and depression, had a physician order for Lorazepam Intensol Oral Concentrate without a documented stop date. The resident's care plan included the use of antidepressant and anti-anxiety medications, with interventions to monitor and document side effects and effectiveness every shift. Resident #15, admitted with severe cognitive impairment and diagnoses of dementia and depression, had a physician order for Quetiapine Fumarate Tablet for agitation, also without a documented stop date. The resident's care plan focused on meeting emotional, intellectual, physical, and social needs related to cognitive deficits, but did not mention the use of psychotropic medication. Interviews with facility staff, including an LPN and the Administrator and DON, confirmed that all PRN psychotropic medications should have a 14-day stop date, and a new order should be obtained if needed.
Incomplete Documentation of Treatments and Hospice Certification
Penalty
Summary
The facility failed to ensure complete and accurate documentation of resident records, specifically for two residents. For one resident, the facility did not document the treatments for a stage four pressure ulcer consistently. The Treatment Administration Record (TAR) showed multiple instances where documentation was left blank, indicating that treatments may not have been completed as ordered. There was no documentation of treatment refusals or notifications to the physician, which is required when treatments are not administered as prescribed. Interviews with staff revealed that treatments should be documented after completion, and if not documented, it is assumed they were not done. Another resident receiving hospice services did not have the required certification of terminal illness form in their medical records or hospice binder. The resident had been admitted to hospice care recently, but the necessary documentation was not available in the facility at the time of the survey. The facility administrator acknowledged the absence of the form and mentioned that the hospice provider was in the process of sending it over. These deficiencies highlight lapses in the facility's documentation practices, which are crucial for ensuring that residents receive appropriate care and that their medical records are maintained according to professional standards. The lack of documentation for treatments and hospice certification could lead to inadequate care and oversight of residents' medical needs.
Infection Control Deficiencies in PPE Use and Signage
Penalty
Summary
The facility failed to adhere to infection control standards by not ensuring staff wore appropriate Personal Protective Equipment (PPE) for two residents and did not post necessary signage for another resident requiring Enhanced Barrier Precautions (EBP). Specifically, staff did not wear gowns while repositioning a resident with an indwelling catheter and stage four pressure ulcers, and the catheter drain was observed touching the floor without being sanitized before being placed back in the holder. This oversight was confirmed through interviews with various staff members who acknowledged the need for sanitation if the catheter drain touched the floor. Another incident involved a resident with a G-tube who was on EBP, yet staff failed to wear gloves or gowns while assisting the resident in the bathroom. The EBP signage on the resident's door was not visible, leading to staff being unaware of the need for PPE. Interviews with the staff involved revealed a lack of awareness about the resident's EBP status, which was attributed to the signage being flipped over and not visible. Additionally, a resident with a suprapubic urinary catheter and MDRO was on EBP, but there was no signage on the door, and PPE supplies were not readily available near the resident's room. Interviews with staff indicated that they relied on door signage and verbal reports to identify residents on EBP, but the absence of visible signage and accessible PPE supplies contributed to the failure to follow proper infection control protocols.
Failure to Document and Administer Ordered Treatments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for residents with specific medical needs. Resident #3, who has a gastronomy tube and is at risk for pressure ulcers, did not receive documented skin observations, Calmoseptine applications, g-tube site care, and wound care as ordered. Observations revealed the g-tube site was not properly dressed, and interviews indicated that the dressing was often missing, suggesting a lack of adherence to care protocols. Resident #1, who had a suprapubic catheter and was at risk for pressure ulcers, also did not receive documented treatments as ordered, including zinc oxide applications, catheter flushes, and wound care. The resident was hospitalized and later expired, but during their stay, there were significant gaps in the documentation of care provided. This lack of documentation implies that the treatments were not administered as required. Additional residents, including Residents #2, #4, #5, and #6, also experienced similar issues with missing documentation for ordered skin treatments and observations. Interviews with the Director of Nursing and the Administrator confirmed that staff are expected to follow orders and document treatments, and any failure to do so should be reported. However, the report highlights consistent failures in documentation and treatment administration across multiple shifts, particularly the evening and agency staff.
Failure to Honor Resident's Caregiver Preferences
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, leading to a deficiency in treating the resident with respect and dignity. The resident, who is cognitively intact and has multiple diagnoses including heart failure and renal failure, expressed a clear preference for female staff during a care plan meeting. Despite this, a male CNA assisted the resident with toileting and bedtime routines, which the resident found distressing. The resident reported that the male CNA was rough and did not respect their wishes regarding personal care routines, such as wearing panties to bed and the placement of their wheelchair and bedside table. The incident occurred when the resident needed assistance to use the restroom and go to bed. The male CNA, identified as CNA A, did not follow the resident's instructions and became frustrated, handling the resident roughly and disregarding their preferences for personal items' placement. The resident had previously communicated their caregiver preferences, which included a list of acceptable staff members, to the staffing coordinator. However, this preference was not honored, leading to the incident and subsequent deficiency finding.
Failure to Follow Fall Policy and Conduct Neurological Checks
Penalty
Summary
The facility failed to adhere to its fall policy by not conducting necessary assessments and neurological checks following falls for three residents. Resident #2 experienced an unwitnessed fall and was sent to the hospital with a head laceration. Upon return, the facility did not document the required neurological checks every four hours for 72 hours, as per policy. Additionally, there was no completed neuro-check form to show the results of assessments, including motor function and pupil response. Resident #9 had an unwitnessed fall resulting in a head injury, but the facility did not complete a fall assessment or document all required neurological checks. The resident was found with a bump on the forehead and skin tears, yet the neuro-checks were not consistently documented, and no neuro-check form was completed to show the results of assessments. Resident #8 had multiple unwitnessed falls, but the facility failed to complete fall assessments for each incident. After a fall on 10/6/24, there were no documented neuro-checks or completed neuro-check forms to show the results of assessments. The facility's failure to follow its fall policy and document necessary assessments and interventions contributed to the deficiency.
Misappropriation of Controlled Substances by LPN
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of controlled substances for 11 residents. This deficiency was identified through interviews and record reviews, revealing that controlled substances were unauthorizedly removed by an LPN. The facility's policy on Resident Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property was not effectively implemented, as evidenced by the unauthorized removal of medications such as oxycodone, Norco, Percocet, and Ativan. The facility's investigation showed that the LPN was observed on video taking narcotics and placing them in their pocket, and discrepancies were noted in narcotic sign-out sheets and Medication Administration Records. The investigation revealed that the LPN had signed out narcotics multiple times without proper documentation and had signed out medication for a resident without an active order. The facility's Controlled Substance policy, which requires accurate accountability and documentation of controlled substances, was not adhered to, leading to the unauthorized removal of medications. The LPN was identified as the individual responsible for the discrepancies, and it was discovered that their nursing license had been previously placed on probation for a similar offense. The deficiency was further compounded by the facility's failure to recognize and investigate the involvement of an additional resident in the misappropriation. The facility's policies on discrepancies, loss, and diversion of medications, as well as controlled substance audits, were not effectively enforced, allowing the LPN to continue unauthorized activities over several days. The facility's lack of timely reporting and investigation of the incidents contributed to the deficiency, resulting in the unauthorized removal of controlled substances from the residents.
Failure to Report Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to report alleged violations involving the misappropriation of controlled substances within the required 24-hour timeframe to the Department of Health and Senior Services (DHSS), law enforcement, and the Board of Nursing. This failure involved two nurses, LPN C and LPN D, and affected 11 residents. The facility's policy mandates immediate investigation and reporting of any suspected abuse, neglect, or misappropriation of resident property, but these procedures were not followed in this instance. The investigation revealed that LPN B was involved in the unauthorized removal of controlled substances, including oxycodone, Norco, Percocet, and Ativan, from the facility. The facility's records showed discrepancies in narcotic sign-out sheets and Medication Administration Records, with LPN B's signature appearing multiple times for medications not documented as administered. Video evidence suggested that LPN B was placing narcotics in their pocket, and LPN B admitted to taking medication not prescribed to them. Despite these findings, the facility delayed reporting the incident to the appropriate authorities. The affected residents, including those with no active orders for pain medication, were subjected to potential harm due to the diversion of their prescribed medications. Resident #11, for example, was cognitively intact and had a history of hip fracture and pain but was not on a scheduled pain medication regimen. The facility's failure to promptly report and address the diversion of medications compromised the safety and well-being of the residents involved.
Failure to Suspend LPN During Investigation Leads to Continued Misappropriation
Penalty
Summary
The facility failed to prevent further misappropriation and diversion of controlled substances by not adhering to its policy of suspending staff during an investigation. LPN C and LPN D reported alleged violations by LPN B, who was accused of misappropriating and diverting medications. Despite these allegations, LPN B was allowed to continue working for three days, during which time the misappropriation continued, affecting nine residents. The facility's policy clearly states that employees alleged to have committed abuse or neglect should be suspended pending investigation, which was not followed in this case. The report highlights specific instances of medication misappropriation involving several residents. For example, Resident #11, who was cognitively intact and had a history of hip fracture and pain, had Norco signed out by LPN B without documentation of administration. Similarly, Resident #15, with severe cognitive impairment and chronic pain, had Percocet signed out more frequently than prescribed, and there was no documentation of administration for MS Contin. These discrepancies indicate a failure to maintain accurate medication records and ensure proper administration. Additionally, the facility failed to conduct thorough investigations into other incidents, such as a resident's missing device and another resident's missing wallet and money. The facility did not submit a completed investigation to the Department of Health and Senior Services within the required timeframe. The lack of comprehensive investigations and timely reporting further demonstrates the facility's failure to adhere to its policies and regulatory requirements, contributing to the overall deficiency.
Failure to Follow Stat X-ray Order and Document Fall Incident
Penalty
Summary
The facility failed to follow a Nurse Practitioner's (NP) order for a stat x-ray of a resident's right shoulder and humerus after the resident experienced a fall while using a rollator walker. The incident was not documented in the resident's medical record, and no investigation into the fall was conducted. The resident, who had severe cognitive impairment and a history of falls, was observed on video footage falling to the floor, after which a dietary aide sought help. A Registered Nurse (RN) assessed the resident and moved them to a wheelchair without documenting the incident or following up on the stat x-ray order. The RN contacted the NP, who ordered a stat x-ray, but the RN was unable to reach the x-ray company and did not document the order or inform the oncoming Charge Nurse. The RN claimed to have been unfamiliar with the facility's electronic health record system, which contributed to the lack of documentation. The resident was monitored overnight without complaints of pain, likely due to their dementia, and the stat x-ray order was not communicated to the next shift. The following day, a Licensed Practical Nurse (LPN) noted the resident's severe pain and swelling in the right arm and contacted the NP, who reiterated the stat x-ray order. The x-ray revealed a complex fracture, and the resident was sent to the hospital for treatment. The Director of Nursing (DON) and Nurse Manager were unaware of the fall and the x-ray order until informed by the LPN. The NP stated that if informed of the inability to contact the x-ray company, they would have ordered the resident to be sent to the hospital immediately.
Failure to Provide Two-Person Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and care as per the care plan for a resident with moderate cognitive impairment and multiple sclerosis, resulting in the resident falling out of bed. The resident's care plan required two staff members to assist with bed mobility and repositioning. However, during perineal care, a CNA attempted to provide care alone, leading to the resident rolling out of bed and sustaining minor abrasions. The CNA was unaware of the two-person assistance requirement, as this information was not readily accessible in the resident's medical record or known to the CNA at the time. Interviews revealed that the facility had a system in place for CNAs to access resident care information via a designated iPhone, but not all staff were familiar with its use. The Director of Nursing and the Administrator acknowledged that CNAs were expected to check the facility's iPhone for care instructions before providing care. However, it was discovered that some CNAs were not aware of this resource or how to use it, leading to a lack of proper communication and understanding of the resident's care needs.
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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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