St Francois Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, Missouri.
- Location
- 1180 Old Jackson Road, Farmington, Missouri 63640
- CMS Provider Number
- 265674
- Inspections on file
- 17
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St Francois Manor during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and a history of stroke and brain dysfunction underwent multiple gradual dose reductions and discontinuations of Depakote and Seroquel ordered by a psych NP, but the resident’s representative was not notified of these medication changes. Facility policy required informed consent and notification of legal representatives for medication regimen changes, yet progress notes and the medical record contained no documentation of such notification or any request by the representative to forgo notifications. The DON reported she believed the guardian did not want to be contacted and therefore had not notified the representative about medication changes, while the Administrator stated she expected policy to be followed and notifications documented.
A resident with chronic low back pain, anxiety, depression, and schizophrenia had a care plan for pain that included medication administration, monitoring, and referral to pain management, but the facility did not follow through on key physician orders and referrals. Although imaging and a pain management consult were ordered and the resident requested stronger pain medication after reporting inadequate relief, the record showed no completed MRI, no documented pain management consult, and no documented alternative pain interventions after the guardian declined a Tramadol increase and requested pain management instead. The facility also lacked policies and procedures for implementing physician referrals and orders and for obtaining informed consent before changing medication regimens.
A resident with severe cognitive impairment and multiple diagnoses pulled out a urinary catheter, resulting in bleeding. There was no documentation that the physician or legal guardian was notified of this change in condition, as required by facility policy. The DON confirmed that staff are expected to notify both parties in such situations.
A resident with multiple complex diagnoses did not have required follow-up appointments with a urologist and nephrologist scheduled, and physician orders for urinary catheterization were not fully implemented or documented. Staff were unaware of certain orders, and monitoring of urine output was inconsistent, leading to a deficiency in care.
A resident with paranoid schizophrenia missed 18 doses of clonazepam due to a failure in the facility's medication ordering and tracking system. Despite staff attempts to manage the situation using emergency kit medications, the resident experienced increased paranoia and aggression, leading to an assault on another resident. The facility lacked a formal procedure for ordering and tracking medications, contributing to the oversight.
The facility failed to provide privacy curtains for two residents, resulting in a lack of privacy. Observations showed no curtains between beds, and residents expressed concerns about privacy and sleep disturbances. Staff interviews revealed confusion over responsibility for curtain installation, with the administrator expecting privacy protection.
The facility failed to provide a safe, clean, and homelike environment, with issues such as structural damage, cleanliness problems, and inadequate maintenance reporting. Residents reported insufficient cleaning, and staff interviews confirmed limited housekeeping duties and unresolved maintenance issues.
The facility failed to identify and address PTSD in the care plans of six residents, despite their diagnoses and documented behaviors. Trauma assessments were not conducted, and care plans lacked personalized triggers and interventions. Interviews with staff revealed a lack of awareness and expectation for addressing PTSD triggers.
A facility failed to ensure accurate medication administration and refills for two residents, leading to missed doses of essential medications. One resident with schizophrenia and PTSD did not receive several doses of Xifaxin and Seroquel XR, while another resident missed doses of medroxyprogesterone. Staff interviews revealed issues with medication refill requests and communication with the pharmacy, resulting in residents not receiving necessary medications.
Expired medications were found in the facility's storage room, including diphenhydramine, clindamycin, and nitroglycerin, despite monthly pharmacy checks. Interviews with staff revealed that the pharmacy had recently reviewed the medication rooms, but expired medications were still present, indicating a lapse in adherence to the facility's policy on medication storage.
Failure to Notify Resident Representative of Psychotropic Medication Changes
Penalty
Summary
Facility staff failed to notify a resident’s representative of multiple changes in the resident’s psychotropic medication regimen, contrary to facility policy requiring informed consent and notification of legal representatives for medication changes. The resident had a quarterly MDS indicating independence in cognitive skills for daily decision-making and activities of daily living, with diagnoses including stroke, non-traumatic brain dysfunction, and traumatic brain dysfunction. The POS and progress notes documented a diagnosis of schizoaffective disorder and a series of gradual dose reductions and discontinuations of Depakote and Seroquel over several months, ordered by a psychiatric NP. These orders included decreasing Depakote doses and ultimately discontinuing it, as well as discontinuing Seroquel. Progress notes recorded each medication change but contained no documentation that the resident’s representative was notified. The facility’s policy on Management of Psychotropic Medications and Unnecessary Medications, dated 04/2025, defined informed consent as providing the resident or legal representative with information about the medication regimen, including risks, benefits, and alternatives, and giving them the opportunity to accept or refuse treatment. Review of the medical record showed no documentation that the resident’s representative had requested not to be notified of medication changes. In an interview, the representative stated they only learned from the resident that medications had been discontinued and confirmed the facility had not contacted them about any dosage changes or discontinuations. The DON stated that facility policy is to contact all resident representatives for any change in condition, including medication changes, and that she is responsible for these notifications, but she had not contacted this resident’s guardian since May 2025 based on her understanding that the guardian did not want to be notified. The Administrator stated she would have expected the DON to follow facility policy and document notifications appropriately.
Failure to Follow Through on Pain Management Orders and Referrals
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with the resident’s comprehensive assessment, care plan, physician orders, and the resident’s goals and preferences. A cognitively intact resident with diagnoses including unspecified low back pain, anxiety, depression, and schizophrenia was care planned for back pain with interventions to administer pain medications as ordered, monitor pain characteristics and effectiveness of treatment, and refer to pain management as ordered. The resident’s MDS indicated frequent pain and use of scheduled, PRN medications and other interventions for pain. Progress notes documented that the resident reported chronic back pain and that existing pain medication was not effective. Physician orders and progress notes showed that an X‑ray, MRI of the lumbar and thoracic spine, and a pain management consult were ordered for low back pain, and later that the resident requested an increase in Tramadol after reporting higher doses received in the hospital. The primary care physician was notified, and a consent form was sent to the guardian for approval of the Tramadol increase, but the guardian refused and preferred that the resident attempt pain management first. The record contained no evidence that the ordered MRI was completed, no documentation of a pain management consult or referral follow‑through, and no documentation of attempts at alternative pain management as requested by the guardian. The facility also lacked policies and procedures for following through on physician referrals and orders, and for obtaining informed consent prior to medication increases or changes in the medication regimen.
Failure to Notify Physician and Guardian After Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician and legal guardian following a significant change in the resident's condition. Specifically, a resident with severe cognitive impairment, cerebral palsy, seizure disorder, anxiety disorder, and a mental disorder, who had a legal guardian, was found to have pulled out their urinary catheter with the balloon still inflated, resulting in blood on the bed mat. Documentation in the resident's progress notes did not indicate that the urinary catheter was re-inserted, nor was there any record that the physician or the guardian was notified of this change in condition. The facility's policy requires staff to observe, record, and report any change in a resident's condition to the attending physician and responsible party to ensure appropriate treatment. During an interview, the DON confirmed that staff are expected to contact both the physician and guardian in such situations. However, in this instance, there was no evidence that these notifications occurred after the resident's condition changed.
Failure to Follow Physician Orders for Catheterization and Specialist Follow-Up
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care for one resident with complex medical needs, including cerebral palsy, seizures, urine retention, obstructive and reflux uropathy, and acute kidney failure. Upon admission, there was no documentation that required follow-up appointments with a urologist and nephrologist were scheduled, despite clear instructions in the hospital discharge summary. Additionally, the facility did not have policies addressing intermittent catheterization or appointment scheduling, and the resident's medical record lacked evidence of assessment for urinary retention or the need for straight catheterization as ordered. Physician orders for urinary catheterization, including specific catheter size, frequency of change, and as-needed straight catheterization, were not fully implemented or documented. After the resident pulled out the urinary catheter, there was no documentation of reinsertion as ordered, and staff interviews revealed a lack of awareness regarding the straight catheterization order. Monitoring of urine output was inconsistent, with staff only documenting bowel movements and not tracking the number of wet briefs or assessing bladder distention as expected. The facility's failure to follow physician orders and ensure complete documentation led to the identified deficiency.
Medication Administration Failure
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for a resident diagnosed with paranoid schizophrenia, insomnia, and anxiety. The resident was prescribed clonazepam 0.5 mg to be administered four times daily. However, the resident missed 18 doses out of 28 opportunities over several days in November 2024. This lapse in medication administration was due to a failure in the facility's medication ordering and tracking system. The issue began when the resident's medication supply ran low, and staff members, including an LPN and a CMT, attempted to manage the situation by using medications from the emergency kit. Despite these efforts, the resident still missed multiple doses. The PNP had ordered the medication, but the pharmacy lost the request, leading to a delay in refilling the prescription. The facility lacked a formal procedure for ordering and tracking medications, which contributed to the oversight. Interviews with staff revealed a lack of communication and a system to ensure medication orders were placed and received in a timely manner. The DON was unaware of the medication shortage until it was too late, and the ADM expected the nursing staff to notify her when medications were low. The absence of a structured process for medication management resulted in the resident experiencing increased paranoia and aggression, culminating in an assault on another resident.
Lack of Privacy Curtains for Two Residents
Penalty
Summary
The facility failed to provide a privacy curtain to maintain privacy for two residents out of 18 sampled residents, with a facility census of 77. Observations on two separate days revealed that the residents did not have a privacy curtain between their beds. Resident #3 was observed lying in bed and folding clothes, while Resident #10 was seen sitting on their bed listening to music. Both residents expressed concerns about the lack of privacy, with Resident #3 mentioning the inability to change clothes privately due to being in a wheelchair and Resident #10 struggling to sleep because of the roommate's TV being visible at night. Interviews with staff members, including a housekeeper and the maintenance director, indicated a lack of clarity regarding responsibility for the installation and maintenance of privacy curtains. The housekeeper stated that housekeeping was not responsible for putting up privacy curtains, and the maintenance director mentioned that they would only address issues if something was broken. The facility administrator expressed an expectation that residents' privacy should be protected, yet the deficiency persisted, leaving the residents without adequate privacy measures.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of deficiencies in various rooms. In several rooms, there were structural issues such as holes in walls and ceilings, missing closet doors, and peeling cove base. Additionally, there were cleanliness issues, including brown films and dots on walls, gray/black fuzzy substances on bathroom vents, and sticky substances on floors. Residents reported that housekeeping only performed basic cleaning tasks and did not address these issues, which were supposed to be reported to maintenance by the staff. Interviews with residents and staff revealed that the cleaning and maintenance processes were inadequate. Housekeeping staff confirmed that their duties were limited to basic cleaning and that they reported environmental issues to their supervisor, who then informed maintenance. However, some issues, like the sticky stain on the floor, remained unresolved. The Director of Nursing and the Administrator acknowledged the expectation for the facility to be clean and in good repair, but the observations indicated a failure to meet these standards, affecting the overall environment for the residents.
Failure to Address PTSD in Resident Care Plans
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for six residents diagnosed with post-traumatic stress disorder (PTSD). These residents were not given trauma assessments, and their care plans did not address PTSD or include personalized triggers and interventions. This deficiency was observed in all six sampled residents, despite their documented diagnoses and behaviors related to PTSD. Resident #3's medical record showed multiple mental health diagnoses, including PTSD, but lacked documentation of a trauma assessment. The care plan did not address PTSD or personalized triggers. Similarly, Resident #17, with a history of sexual abuse and multiple mental health disorders, reported that staff had not discussed PTSD or triggers since admission. The care plan for Resident #17 also failed to address PTSD or personalized interventions. Other residents, including Resident #27, #33, #41, and #51, also had PTSD diagnoses without corresponding trauma assessments or care plans addressing their specific needs. Interviews with staff, including a CNA, RN, SSD, DON, and the Administrator, revealed a lack of awareness and expectation that PTSD triggers should be assessed and addressed in care plans, highlighting a systemic issue in the facility's approach to trauma-informed care.
Medication Administration and Refill Failures
Penalty
Summary
The facility failed to ensure accurate administration, documentation, disposal, and reconciliation of medications for two residents. Resident #3, who has multiple diagnoses including schizophrenia and PTSD, did not receive several doses of prescribed medications, including Xifaxin and Seroquel XR, over a period of days. The resident reported not receiving medications necessary for sleep and to prevent hallucinations. The facility's medication administration record (MAR) confirmed the missed doses. Resident #8, diagnosed with schizophrenia, also experienced missed doses of medroxyprogesterone over several days. Interviews with staff revealed that the facility had issues with medication refills and communication with the pharmacy. LPN I was unaware of the medication shortages, and CMT E explained the process for ordering medications, which included using a system link or faxing orders to the pharmacy. The pharmacy confirmed that medications were sent on the same day they were requested, but the facility failed to request refills in a timely manner or follow up on inquiries about refill timing. The Director of Nursing and the Administrator acknowledged that medications should be ordered before they run out. The facility's failure to manage medication orders and refills resulted in residents not receiving necessary medications, highlighting a breakdown in communication and procedure adherence within the facility.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted practices, which had the potential to affect all residents. During an observation of the medication storage room, it was found that there were four unopened vials of diphenhydramine with an expiration date of 03/2024, six tablets of clindamycin with an expiration date of 04/12/24, and one unopened bottle of nitroglycerin sublingual tablets with an expiration date of 04/20/24. These findings indicate that expired medications were present in the storage room, contrary to the facility's policy that requires outdated or deteriorated medications to be immediately removed from inventory and disposed of according to procedures. Interviews with staff revealed that the pharmacy visits the facility once a month to review the medication rooms and carts, with the most recent review occurring on 06/10/24. However, the presence of expired medications suggests that the monthly checks were insufficient or not thoroughly conducted. The Director of Nursing and the Administrator expressed that they expected the medication rooms and carts to be checked for expired medications at least monthly, ideally twice a month, indicating a gap between policy expectations and actual practice.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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