St Joe Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bonne Terre, Missouri.
- Location
- 10 Lake Drive, Bonne Terre, Missouri 63628
- CMS Provider Number
- 265701
- Inspections on file
- 20
- Latest survey
- February 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St Joe Manor during CMS and state inspections, most recent first.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, as required by policy. This deficiency affected multiple residents, with no documentation of written notifications at the time of transfer. Interviews with staff revealed that the responsibility for sending transfer forms lies with floor nurses, but the expected notifications were not documented.
The facility failed to provide written information about the bed hold policy to residents and/or their representatives at the time of hospital transfer. This deficiency was noted for four residents, despite the facility's policy requiring such information to be given in writing. Interviews indicated that floor nurses were responsible for this task, but documentation was lacking.
The facility failed to accurately document MDS assessments for four residents, leading to discrepancies in recorded medical information. A resident's MDS inaccurately recorded insulin injections, while another's did not reflect hospice status. The facility lacked a policy on MDS accuracy, contributing to these errors, despite expectations from the MDS Coordinator and administration for accurate assessments.
The facility failed to implement comprehensive care plans for four residents, resulting in deficiencies in addressing their individual needs. A resident with paraplegia used side rails not included in their care plan. Another resident with sleep apnea used oxygen and a BIPAP machine, which were not documented. A third resident with COPD used oxygen therapy not reflected in their care plan. Lastly, a resident with chronic UTIs was on antibiotics, but their care plan did not address UTI management. The facility's policy requires care plans to be updated, but this was not followed.
The facility failed to update and revise care plans for several residents, leading to deficiencies in addressing individual needs. A resident's care plan did not address vape use, another was inaccurately listed as full code despite hospice care, and a third was not informed about care plan meetings. Additionally, a resident with multiple falls had outdated fall risk interventions, and another's care plan lacked bleeding precautions for an anticoagulant. The administration acknowledged the expectation for care plans to reflect current conditions.
Two residents in the facility did not receive consistent showers as per their scheduled ADLs, leading to extended periods without proper hygiene. One resident, with multiple health conditions, reported receiving showers only once every two weeks, while another resident with Parkinson's disease reported having only one shower a month. Staff interviews confirmed that residents should receive two showers per week, but records showed multiple missed opportunities.
A facility failed to obtain a physician's order for oxygen administration and did not ensure a BIPAP order included settings for a resident with multiple respiratory and cardiac conditions. The resident was observed using oxygen and a BIPAP machine without documented orders, and staff interviews confirmed the lack of necessary orders.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate due to improper insulin administration. Three residents were affected as insulin pens were not primed before use, contrary to manufacturer instructions. CMTs misunderstood the priming process, believing it was only necessary when the pen was first used. The ADON and DON confirmed the expectation to follow manufacturer's guidelines.
A facility failed to maintain proper infection control practices during foley catheter care for a resident. A CNA did not adhere to the facility's Handwashing/Hand Hygiene Policy and EBP policy, failing to perform hand hygiene between tasks and not wearing a gown as required. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
A facility failed to follow infection control practices during perineal care for a resident with a PICC line. Staff did not adhere to the Enhanced Barrier Precaution (EBP) policy, which required wearing gowns, gloves, and masks. Observations showed that CNAs did not wash hands before donning gloves or after removing them, and did not clean the area before placing a brief. Interviews revealed a lack of understanding of EBP requirements, and the administration acknowledged the failure to follow policy.
Facility staff failed to report a resident-to-resident abuse incident to the state licensing agency. A resident pushed another, causing a fall and head injury requiring staples. The DON did not report the incident, believing it unnecessary unless harm occurred, despite the facility's policy requiring such reports. The Administrator expected the incident to be reported, highlighting a protocol discrepancy.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing of transfers or discharges to a hospital, including the reasons for such transfers, for eleven residents out of 28 sampled and one additional resident outside the sample. This deficiency was identified through interviews and record reviews, revealing a lack of documentation that the residents' representatives were informed in writing at the time of transfer. The facility's policy, revised in October 2022, mandates written notification to residents and their representatives, including specific details about the transfer or discharge, the effective date, and the new location. The policy also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. However, the review showed that for multiple residents, including those who were transferred to the hospital on various dates, there was no documentation of written notification to the residents' representatives. The facility's policy considers transfers to acute care settings as facility-initiated transfers, not discharges, and expects residents to return to the facility. Despite this, the required notifications were not documented. Interviews with facility staff, including the Social Services Designee and Registered Nurse, indicated that the responsibility for sending out transfer forms lies with the floor nurses. The Administrator, Director of Nursing, and Assistant Director of Nursing acknowledged the expectation that residents and their representatives should be notified in writing of transfers. The lack of documentation for these notifications constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the facility's bed hold policy at the time of transfer to the hospital. This deficiency was identified for four residents out of a sample of 28, despite the facility's policy requiring that such information be provided in writing at least twice: in advance of any transfer and at the time of transfer. The policy, revised in October 2022, mandates that residents and their representatives be informed of the bed hold policies, which address holding or reserving a resident's bed during periods of absence, such as hospitalization or therapeutic leave. Interviews with facility staff revealed that the responsibility for sending out the bed hold policies lies with the floor nurses at the time of resident discharge. However, there was no documentation in the medical records of the four residents indicating that they or their representatives were informed in writing of the bed hold policy at the time of their transfers to the hospital. The facility's administration, including the Administrator, Director of Nursing, and Assistant Director of Nursing, collectively acknowledged the expectation that residents and/or their representatives should be made aware of bed holds in writing.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the recorded medical information. Resident #40's medical record indicated that they received an injection of Ozempic but did not receive insulin during the seven-day look-back period. However, the MDS assessment inaccurately recorded that the resident received one insulin injection. Similarly, Resident #41's record showed an injection of Ozempic without any insulin received, yet the MDS assessment incorrectly noted one insulin injection. Resident #131's medical record documented two Haldol injections, but the MDS assessment marked zero injections received in the look-back period. Lastly, Resident #138, who was admitted to hospice, had an MDS assessment that inaccurately marked 'no' for a condition that may result in a life expectancy of less than six months. The facility did not provide a policy regarding MDS accuracy, which may have contributed to these inaccuracies. Interviews with the MDS Coordinator and the facility's administration, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed an expectation for MDS assessments to accurately reflect the residents' conditions at the time of assessment. Despite this expectation, the discrepancies in the MDS documentation for these residents indicate a failure to meet this standard, as evidenced by the inaccurate coding of injections and hospice status.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans with specific interventions for four residents, leading to deficiencies in meeting their individual needs. Resident #31, who has diagnoses including paraplegia and rheumatoid arthritis, was observed using side rails for mobility, yet their care plan did not address the use of side rails. This oversight indicates a lack of alignment between the resident's needs and the documented care plan. Resident #41, diagnosed with obstructive sleep apnea and other respiratory conditions, was observed using oxygen and a BIPAP machine, but their care plan did not include these critical interventions. Similarly, Resident #55, with COPD and atrial fibrillation, was using oxygen therapy, which was not reflected in their care plan. These omissions suggest a failure to update care plans to reflect the residents' current medical needs and prescribed treatments. Resident #111, who has a history of chronic UTIs and other health issues, was taking antibiotics for a UTI, yet their care plan did not address the management of chronic UTIs. The facility's policy requires care plans to be updated with measurable objectives and time frames, but these were not adhered to, as evidenced by the lack of updates in response to significant changes in the residents' conditions. The facility's administration acknowledged the expectation for care plans to be current and reflective of residents' conditions.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of five residents. Resident #1's care plan did not address the use of vapes, despite observations of the resident having a vape in their room and on their lap. Additionally, the resident reported not taking any medications, yet the care plan included several medication-related interventions. Resident #6's care plan inaccurately listed the resident as a full code, despite an order for hospice care and a DNR status. Resident #18 was not informed about upcoming care plan meetings, and there was no documentation to indicate that the resident was notified, despite expressing a desire to attend these meetings. Resident #34 experienced twelve unwitnessed falls, including falls with injuries, but the care plan's fall risk interventions had not been updated since August 2023. This lack of updated interventions occurred despite a significant change in the resident's condition, as indicated by a recent MDS assessment. Resident #126's care plan failed to address bleeding precautions and interactions related to the prescribed anticoagulant, Apixaban. Additionally, the care plan did not address the resident's use of marijuana, despite noting the resident's unsupervised smoking and vaping habits. The facility's administration acknowledged the expectation for care plans to reflect the current condition of residents, which was not met in these cases.
Inconsistent Shower Schedule for Residents
Penalty
Summary
The facility failed to provide consistent care for activities of daily living (ADLs) for two residents, resulting in extended periods without showers. Resident #24, who has multiple health conditions including arthritis, spinal stenosis, COPD, diabetes, heart failure, morbid obesity, and severe chronic kidney disease, reported receiving showers only once every two weeks despite being scheduled for twice a week. The resident expressed feeling dirty and uncomfortable with facial hair due to the infrequent showers. Records showed that in December 2024, the resident missed six out of nine scheduled showers, and in January 2025, missed another six out of nine. Similarly, Resident #55, diagnosed with Parkinson's disease, COPD, heart failure, and other conditions, reported having only one shower a month, despite being scheduled for two per week. The resident expressed concern about personal hygiene and odor. Records indicated that in December 2024, the resident missed seven out of nine scheduled showers, and in January 2025, missed eight out of nine. Interviews with staff, including a CNA, RN, ADON, and DON, confirmed that residents should receive two showers per week, but the facility failed to adhere to this schedule consistently.
Failure to Obtain Orders for Oxygen and BIPAP Settings
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration and did not ensure that a physician's order for bilevel positive airway pressure (BIPAP) included the necessary settings for a resident. This deficiency affected one resident who had multiple diagnoses, including obstructive sleep apnea, shortness of breath, respiratory failure, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease. The resident was observed using oxygen via nasal cannula at 3.5 liters per minute and had a BIPAP machine at bedside, but there were no documented orders for the oxygen or the BIPAP settings. Interviews with the resident and facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, confirmed the lack of necessary orders. The resident reported regular use of oxygen and BIPAP at bedtime, while the staff acknowledged that orders for oxygen and BIPAP settings should be in place. The facility's policy required a review of the physician's order for BIPAP settings, but this was not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency affected three residents out of seven sampled. The errors were related to the improper administration of insulin using pen-type devices, specifically the failure to prime the insulin pens before administration, as required by the manufacturer's instructions. This oversight was observed in the administration of both NovoLog and Insulin Lispro to the residents. Resident #32 received three units of NovoLog without the pen being primed, despite a blood sugar level of 204. Similarly, Resident #102 was administered six units of Insulin Lispro without priming the pen for a blood sugar level of 236. Resident #133 also received three units of Insulin Lispro without the pen being primed. Interviews with the Certified Medication Technicians (CMTs) involved revealed a misunderstanding of the priming process, as they believed priming was only necessary when the pen was first used. The Assistant Director of Nursing and the Director of Nursing confirmed that staff are expected to follow the manufacturer's guidelines for insulin administration.
Infection Control Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter care for a resident. The facility's Handwashing/Hand Hygiene Policy and EBP policy were not adhered to by a Certified Nursing Aide (CNA) during the care of a resident with a foley catheter. The CNA did not wash or sanitize hands before donning gloves, did not wear a gown as required by EBP, and failed to perform hand hygiene between dirty and clean tasks and before leaving the resident's room. During the observation, the CNA was seen entering the resident's room, donning gloves without prior hand hygiene, and not wearing a gown despite EBP signage and supplies being accessible. The CNA performed catheter care and peri care without proper hand hygiene between tasks and left the room with trash without sanitizing hands. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene between tasks and before leaving the room. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
Infection Control Deficiency During Perineal Care
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal care for a resident with a Peripherally Inserted Central Catheter (PICC). The facility's Perineal Care Policy and Enhanced Barrier Precaution (EBP) Policy were not followed. During an observation, it was noted that a Certified Nursing Aide (CNA) donned gloves without washing hands and performed perineal care without cleaning the area first. Additionally, the CNA did not wash hands after removing gloves and before leaving the room. The EBP signage on the resident's door indicated the need for protective gear, but the staff did not adhere to these guidelines. Interviews with the staff revealed a lack of understanding and adherence to the EBP policy. CNA A and CNA B did not wear the required gown, gloves, and mask during care for the resident with a PICC line, despite the policy indicating that EBP should be used for residents with such devices. The Licensed Practical Nurse (LPN) confirmed that EBP should be worn for residents with medical devices like a PICC line. The resident also reported that staff had not been wearing gowns during care, only masks and gloves during PICC line care. The facility's administration acknowledged that the staff should have followed the policy and washed hands between dirty and clean tasks.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility staff failed to report an incident of resident-to-resident abuse to the state licensing agency as required. The incident involved two residents, where one resident pushed another, resulting in a fall that caused a head injury requiring two staples and a skin tear on the elbow. The facility's policy mandates reporting such incidents to the state agency, but this was not done. The Director of Nursing (DON) was informed by the state licensing agency that reporting was not necessary unless harm occurred, which led to the decision not to report the incident. The incident occurred when one resident accused another of stealing food and pushed them, causing the fall. The facility's investigation noted the fall was unwitnessed and did not initially observe injuries on the resident who fell. However, the resident was later transferred to the hospital due to the injuries sustained. The Administrator expressed that such incidents should be reported to the state licensing agency, indicating a discrepancy between the facility's actions and the expected protocol.
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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