St Peters Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Peters, Missouri.
- Location
- 5400 Executive Centre Parkway, Saint Peters, Missouri 63376
- CMS Provider Number
- 265824
- Inspections on file
- 29
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at St Peters Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility failed to implement RD recommendations and physician orders for fortified diets, finger foods, and nutritional shakes, and failed to provide needed meal set-up and encouragement for two residents with severe cognitive impairment and documented significant weight loss. One resident, ordered a fortified diet and later finger foods due to roaming during meals, continued to receive standard plated meals without finger foods, had no care-plan updates, and was observed having trays placed without set-up assistance and removed uneaten without encouragement or alternative offerings. Another resident with dysphagia and a fortified mechanical soft diet, ordered high-calorie nutritional shakes twice daily after further weight loss, did not receive the shakes at breakfast or lunch, and staff removed largely uneaten trays without supervision, encouragement, or substitutions, while the DM and dietary staff acknowledged that RD recommendations and diet orders were not correctly reflected on meal cards or implemented.
The facility failed to follow its own policy and federal resident rights requirements when moving several residents from long‑standing private rooms to semi‑private or LTC rooms. Cognitively intact and cognitively impaired residents with significant medical conditions, including quadriplegia, dementia, heart failure, and prior stroke, were told by an ADON, SW, or an individual identifying as the Administrator that they would be moved to accommodate isolation, COVID, rehab, or acuity‑based staffing needs. Families reported being informed by phone that moves would occur within a short timeframe, with notes documenting only vague "consent" and no written notices explaining the reasons for the moves. Residents and families were not offered choices of rooms or roommates, were not introduced to new roommates in advance, and were not informed they could refuse the moves, despite facility policy stating residents have the right to written notice, to share a room with a roommate of choice, and to refuse room changes unless necessary for health or safety.
The facility failed to provide required written discharge notices, including appeal rights and bed-hold information, to three residents who were dependent on staff for ADLs and were cognitively intact or impaired. As part of a unit reconfiguration to free up rehab beds, residents were told by phone they had to move within a short timeframe and were discharged to other SNFs without documented 30‑day or emergency discharge notices. Families reported they were not offered in‑house room alternatives, felt they had no choice, were not informed of appeal rights, and did not receive written discharge notices. Social workers reported they were directed by an administrator to move residents to open rehab beds and believed written notices were unnecessary for SNF‑to‑SNF transfers, resulting in discharges that did not comply with required notification standards.
Staff improperly used a mechanical lift’s emergency release button to rapidly lower a dependent resident with Parkinson’s disease, Alzheimer’s disease, dementia, and severe cognitive impairment onto a bed, contrary to facility policy requiring slow, controlled lowering. Video showed two CNAs transferring the resident from wheelchair to bed, with one CNA asking about dropping the resident and then pressing the emergency release, causing a quick drop that startled the resident and moved the bed. The DON confirmed there was no equipment malfunction and that the emergency release should only be used in true emergencies, while the CNA who operated the lift stated they used the button because the lift lowered residents very slowly and believed they had not been instructed not to use it during transfers.
Two residents with dementia and Alzheimer's disease were not treated with dignity and respect by CNAs, who failed to greet or explain care, used forceful and disrespectful language, left residents exposed, and engaged in argumentative and mocking exchanges during ADL assistance, as documented by video footage and family reports.
Two residents who required two-person assistance for mechanical lift transfers due to conditions such as dementia and Parkinson's disease were transferred by staff without consistent two-person support, contrary to facility policy. Video evidence and staff interviews confirmed that only one CNA operated the lift while the other was not assisting, resulting in residents being left unsupported and swinging in the lift during transfers.
Staff did not adhere to infection control protocols during personal care for two residents who were dependent for ADLs and incontinent. CNAs failed to perform hand hygiene before care, used the same gloves for both clean and dirty tasks, and handled clean supplies, bedding, and room equipment without changing gloves or washing hands, despite being aware of facility policy.
Several residents were awakened, dressed, and brought to common areas earlier than their stated preferences, despite care plans and facility policy supporting resident choice. Staff followed a predetermined list for morning routines, resulting in residents with cognitive and physical impairments being up before their desired times and expressing dissatisfaction. This practice did not align with the documented directives for resident self-determination and dignity.
Staff failed to consistently use Enhanced Barrier Precautions and proper hand hygiene during high-contact care for two residents with indwelling medical devices. Observations showed that required PPE, such as gowns and face shields, was not used, and hand hygiene protocols were not followed between tasks. Interviews revealed staff confusion about EBP requirements, leading to lapses in infection control practices.
The facility failed to maintain the dish machine at the required temperature and ensure kitchen cleanliness, affecting all residents receiving meals. The dish machine's wash and rinse cycles only reached 100°F, below the required 120°F, with no temperature documentation. The kitchen had grease and debris build-up, and the RD was unaware of these issues.
The facility failed to provide a dignified dining experience for several residents. Staff were observed standing while assisting severely cognitively impaired residents with meals, contrary to policy. One resident waited 48 minutes for an alternative meal after refusing the initial offering. Another resident, with intact cognition, felt unloved due to being served last at a table where others had already started eating. These actions indicate a failure to adhere to the facility's dining assistance policy.
A resident with severe cognitive impairment and malnutrition experienced significant weight loss due to the facility's failure to implement prescribed nutritional interventions. Observations revealed that the resident was not consistently provided with the fortified diet and chocolate milk as ordered, and staff did not encourage meal consumption. Interviews with staff indicated a lack of awareness and adherence to dietary interventions, contributing to the resident's poor nutritional intake.
The facility failed to ensure proper garbage disposal practices, as observed with open dumpster lids and food debris spillage. Despite the policy requiring closed lids, staff did not consistently comply, posing a risk of attracting pests.
A facility failed to submit a discharge return anticipated (DCRA) MDS assessment for a resident within the required timeframe. The assessment, with an ARD of 09/15/24, was completed but not submitted, as confirmed by the MDS Coordinator. This oversight could potentially affect care planning and provision or payment to other facilities.
The facility failed to create comprehensive care plans with measurable goals for two residents prescribed psychoactive medications. One resident's care plan lacked goals for antipsychotic medication, while the other had unmeasurable goals due to missing baseline data. The DON confirmed the absence of necessary documentation to track medication effects.
A resident with severe cognitive impairment experienced distress due to delayed toileting assistance, while another resident with a catheter lacked necessary orders for its management. The facility's limited CNA availability contributed to the toileting delay, and an oversight in transferring urology orders led to missing catheter care documentation.
The facility failed to document indications for psychotropic medication use and monitor their efficacy for two residents. One resident was prescribed quetiapine without documented justification, and another was on multiple psychoactive medications without monitoring target behaviors. This lack of documentation and monitoring could affect the ability to prescribe the lowest effective dose.
A resident with a history of heart failure and other conditions was not asked about her food preferences, leading to repeated servings of disliked items such as scrambled eggs. Despite being cognitively intact and having a care plan that required catering to her preferences, the dietary interview sections were left blank, and the dietary manager and registered dietitian were unaware of her dislikes.
The facility failed to provide proper written transfer notices to three residents transferred to the hospital, lacking details such as the reason, location, and appeals process. Interviews revealed staff did not adhere to the facility's policy, leading to deficiencies in communication and documentation.
A facility failed to provide a complete bed hold notice to a resident or their representative during an emergent transfer to the hospital. The notice lacked financial information, such as the daily cost, required by facility policy. The resident, with multiple medical diagnoses, was transferred due to a change in a feeding tube's position. Staff interviews confirmed the omission, and there was no documentation of the notice being mailed promptly.
The facility did not serve meals at an appetizing temperature, as residents who ate in their rooms reported that the food was often cold. This issue was identified through observations, interviews, and record reviews, with the facility having a census of 115 residents.
The facility did not inform five residents or their representatives about potential charges for respiratory therapy services not covered by Medicare/Medicaid or the facility's per diem rate. These residents were charged without prior notification, as identified during interviews and record reviews.
A resident with Alzheimer's and other medical conditions did not receive prescribed medications for a UTI due to a failure in entering verbal orders into the medication administration record. The ADON received orders for a probiotic and to switch antibiotics, but these were not documented, leading to the resident's hospitalization with pyelonephritis. Interviews revealed communication lapses and expectations for immediate reporting of lab results.
The facility failed to maintain a licensed nursing home administrator, as required by state law, affecting all residents. The administrator's temporary license expired, yet he continued to perform duties, including issuing a discharge notice. An interim administrator was delayed in starting, and the Regional President acknowledged the lapse in compliance.
The facility did not have a qualified Infection Preventionist (IP) for some time, leading to a lack of infection tracking and control. The Director of Nursing (DON) recently obtained her IP certification, but during the absence of a designated IP, there was no monitoring of infections or antibiotics. The DON noticed a trend in urinary tract infections but was unaware of the affected residents or the actions being taken. The Administrator expected infection tracking to be in place.
The facility failed to follow the planned menu reviewed by the RD, resulting in discrepancies between the menu and meals served. Meals often did not match the menu, and correct serving sizes were not provided. For example, chicken rice soup was not prepared, and no substitute was available. A resident expressed dissatisfaction with receiving only half a BLT sandwich, and the RD was unaware that the facility was not following the approved spreadsheets for meal preparation.
A facility failed to provide an appropriate discharge notice for a resident with severe cognitive impairment, lacking a proper discharge location and necessary appeal information. The resident's physician did not document unmet needs, and the facility did not assist the DPOA in finding alternative care. The administrator was unaware of documentation requirements.
The facility failed to maintain a kitchen faucet, resulting in continuous water flow. Despite multiple work orders submitted by the Dietary Manager, the Maintenance Director marked the issues as resolved, but the problem persisted. The Administrator was unaware of the issue, indicating a communication breakdown in the maintenance process.
A resident who fell and was in pain did not receive a timely x-ray or pain management. A STAT mobile x-ray was ordered but delayed, and results were not promptly communicated to the physician. The resident was later diagnosed with a fractured shoulder. Pain medication orders from the emergency room were not followed until 12 days after the injury.
The facility failed to address significant weight loss in three residents, with one resident losing 5.9% of their weight over five months, another losing 9.3% in three months, and a third losing 17% in seven months. The facility did not notify the physician or RD about these losses, nor did it implement or evaluate interventions. Specifically, interventions for one resident were not communicated or implemented as recommended by the RD.
The facility was found to have unsanitary kitchen conditions, including unclean floors with food, debris, and rodent feces, and equipment surfaces with rodent feces. Staff failed to label and date opened food, improperly stored food, and did not discard compromised items like ice cream and apples. The facility had 117 residents during the survey.
The facility failed to maintain an effective pest control program, leading to the presence of rodents in the kitchen. This issue was identified through observation and interview during a survey, with the facility having a census of 117 residents.
A facility failed to provide appropriate care for a resident with dementia, who exhibited behaviors affecting themselves and others. Despite recognizing these behaviors, the facility did not evaluate or implement further care approaches. The resident's increased behaviors led to the use of anti-anxiety IM and psychotropic medications without trying alternative interventions. Although a psychiatric consultation was ordered, it was not scheduled, leading to continued behavior issues and increased medication use.
A resident with severe cognitive impairment fell and sustained a shoulder fracture. The facility delayed obtaining a STAT x-ray and failed to administer pain medication or alternative interventions. The x-ray results were not communicated to the physician promptly, delaying the resident's transfer to the ER. Additionally, the facility did not follow the hospital's discharge orders for pain management, resulting in the resident experiencing prolonged pain.
The facility failed to monitor and address significant weight loss in three residents, leading to a deficiency in providing adequate nutrition. One resident with severe cognitive impairment was not assisted with meals, resulting in a 5.9% weight loss over five months. Another resident experienced a 9.3% weight loss in three months without proper documentation or physician notification. A third resident, at risk for malnutrition, was not provided with fortified foods, leading to a 17% weight loss in seven months. The facility did not notify the physician or implement interventions to address these issues.
The facility failed to maintain sanitary conditions in the kitchen and kitchenette, leading to a health deficiency. Observations showed contamination with rodent feces and improper food storage, labeling, and dating. Staff interviews confirmed awareness of the rodent problem and unsanitary conditions, with reports shared among administration. Despite this, facility policies on sanitization and pest control were not effectively implemented.
The facility failed to inform several residents or their representatives about respiratory therapy services not covered by Medicare/Medicaid before providing these services. Residents were charged without prior notification, and the facility lacked a policy for the respiratory therapy department. Interviews revealed that residents and their representatives were unaware of the services and associated costs, leading to confusion and billing issues.
The facility failed to provide necessary oral hygiene care for five residents unable to perform their own ADLs. Observations showed food particles and white substances on their teeth, and interviews revealed missing or unused oral care supplies. Staff interviews indicated challenges with agency staff compliance, and the DON acknowledged difficulties in ensuring oral hygiene tasks were completed.
The facility failed to follow the planned menu and serve correct portion sizes, leading to inconsistencies in meal service. Observations showed random meal serving order, missing menu items, and improper portioning. Interviews revealed a lack of recipes and oversight in the kitchen, with the Administrator assuming responsibility due to the absence of a dietary manager.
The facility failed to serve food at appetizing temperatures, with residents reporting cold meals in their rooms. Records showed no food temperatures were taken for several meals, and a test tray revealed food served below required temperatures. The dietary manager had recently quit, leaving the administrator to oversee the kitchen.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions like indwelling catheters and pressure ulcers, lacking a specific policy and staff awareness. Observations showed inadequate signage and PPE availability, with staff interviews revealing a lack of understanding of EBP. The Director of Nursing admitted reliance on a general contact isolation policy, which did not cover EBP requirements.
The facility's kitchen was found to have a significant rodent infestation, with numerous instances of rodent feces observed on various surfaces and food particles scattered throughout. The Dietary Manager, Maintenance Director, and Registered Dietician were aware of the issue, which had persisted despite pest control efforts. The problem was exacerbated by a shortage of staff and nearby construction, as noted by the Administrator.
The facility failed to ensure medications were not left in resident rooms without proper orders, affecting three residents. Medications, including Nystatin Powder, artificial tears, Clear Eyes eye drops, Mineral Cream, and triple antibiotic ointment, were found improperly labeled or without orders. Staff and residents were unable to identify the owners of these medications, and the DON confirmed that medications should not be left in rooms without self-administration orders.
A resident with dementia exhibited increased behavioral issues, but the facility failed to evaluate and implement appropriate interventions, relying instead on medications without attempting alternatives. Despite an order for psychiatric consultation, it was not scheduled, leading to continued behavioral problems and increased medication use. Interviews revealed a lack of communication and follow-through regarding psychiatric care.
The facility failed to comply with state laws by appointing an acting administrator who was not licensed in the state as a nursing home administrator. The acting administrator, in the role for about a week, admitted to not holding a state license and not contacting the state licensing board for a temporary license. This oversight had the potential to affect all 118 residents.
Failure to Implement Diet Orders and Provide Meal Encouragement for Residents With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement registered dietician (RD) recommendations and physician orders for fortified diets, finger foods, and nutritional shakes, as well as failure to provide meal encouragement and assistance for two residents with significant weight loss. Facility policy required evaluation of undesirable weight changes, multidisciplinary care planning, and individualized interventions such as supplements and functional supports for eating. For Resident #1, who had severe cognitive impairment and required set-up assistance with meals, the care plan for weight listed only a fortified regular diet with regular texture and an RD evaluation as needed, despite documented significant weight loss. Resident #1’s weight decreased from 124 pounds in early January to 115.4 pounds in early February, reflecting approximately a 7% loss in 30 days, and then to 106.2 pounds by early March, reflecting further significant loss. The RD documented variable intake (0–100%), noted that the resident did not like the food and roamed during meals, and recommended weekly weights and later the addition of finger foods. A physician order for finger foods was entered, but the care plan was not updated to address the weight loss or the new intervention. Observations showed that the resident was served a plate with pie, a roll, and a honey bun, without any finger foods listed on the diet card, and no finger foods were actually provided. Staff did not encourage the resident to eat the plated meal or offer alternatives when the resident left the table, and the uneaten meal was removed without attempts at meal encouragement. Further observations for Resident #1 showed that breakfast and lunch trays were placed at the bedside while the resident was in bed with eyes closed, with silverware still wrapped and no set-up assistance provided, despite the MDS indicating a need for set-up help. Staff removed full, uneaten trays from the room without attempting to wake or encourage the resident to eat and without offering different food options. The Dietary Manager (DM) acknowledged that finger foods had not been served, was unaware of the finger food order on the physician order sheet, and stated it was the DM’s responsibility to ensure new dietary orders were implemented. The ADON reported that staff tried finger foods briefly, then stopped without notifying the RD or trying other interventions, and the RD stated he/she was not aware that finger foods were not being offered and expected to be notified if recommendations were not followed. For Resident #2, who had dysphagia, severe cognitive impairment, and required supervision with eating, multiple weights in January and early February showed a downward trend, with a 6.4% weight loss in 30 days by late February. The RD recommended a fortified diet with mechanical soft texture and chopped meats, and the diet order was changed accordingly. A care plan for malnutrition was initiated, including interventions such as allowing adequate time for meals, assisting with meals/fluids as needed, obtaining weights as ordered, and providing diet and supplements per physician order. By early March, the resident’s weight had decreased further to 112 pounds, reflecting a 5.7% loss in 30 days and 10.8% in 90 days, and the RD recommended high-calorie, high-protein nutritional shakes twice daily, which were ordered by the physician. Despite the order for nutritional shakes twice daily, observations showed that Resident #2 did not receive nutritional shakes with breakfast or lunch. The resident’s diet card did not indicate the shakes, and staff did not provide them. At breakfast, the resident received a tray with French toast, chopped bacon, and scrambled eggs, ate only a few bites, and staff removed the tray without encouraging further intake or offering alternatives. At lunch, the resident was served chopped pork chop, mashed sweet potatoes, and broccoli, with no nutritional shake provided and no staff present in the dining room to assist; the resident did not eat any of the food. The DM confirmed that dietary staff were responsible for serving nutritional shakes on meal trays, acknowledged that the shakes were not listed on the meal card, and admitted missing the RD recommendations for both residents. A dietary aide stated not being aware of the nutritional shake order and confirmed not providing shakes at breakfast or lunch. The DON and Administrator both stated they expected staff to follow physician orders and RD recommendations, but the documented observations and interviews showed that these orders and recommendations were not implemented for the two residents with significant weight loss.
Failure to Provide Written Notice and Honor Resident Choice in Room and Roommate Changes
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights related to room changes, including the right to receive written notice of a room or roommate change, the right to share a room with a roommate of choice, and the right to refuse a room move unless necessary for health or safety reasons. The facility’s own undated policy stated that room or roommate changes may occur when the facility deems it necessary or when requested by the resident, that resident preferences are to be considered, and that residents have the right to share a room with a spouse, domestic partner, or friend. The policy also required that all parties receive verbal or written notice prior to a room or roommate change, that written notice include the reason for the change and information to help the new roommates become acquainted, and that residents have the right to refuse a room move without affecting Medicare or Medicaid eligibility. Despite this, multiple residents were moved without written notice, without being offered choices of rooms or roommates, and without being informed they could refuse the move. One cognitively intact resident with quadriplegia, anxiety, and depression had been in a private room for over two years and was moved to a semi‑private room. A progress note documented that the ADON and social worker (SW) called the resident’s POA about the move and that the POA was agreeable, and that the resident was told he/she would be moving the next day. The note did not document any written notice or explanation of the reason for the move. The resident later reported being very upset about losing the long‑standing private room, stated that he/she was not given an option and was simply told by the SW and ADON that the move would occur the next day, and described staff coming in the next morning and moving him/her. The resident and family reported that many decorations and belongings had to be taken home due to lack of space, and that staff “shoved” belongings into boxes and did not offer to put them away. The POA stated that the SW had emailed that the resident was being moved to make room for potential isolation patients, that no choice of rooms was given, and that neither the POA nor the resident were told they could refuse the move. Another resident with cognitive impairment, heart disease, hypertension, diabetes, and a history of stroke was also moved from a private room. A progress note by the SW documented a call to two family members about a room change and that “consent” was obtained, but did not specify what the consent covered or provide any written notice. The family members reported being told by the SW that the resident would be moved to another room to create a quarantine room for potential hospital admissions and that the move had been approved by the Administrator. They stated they were told they had three days to move the resident, were not offered any alternative rooms, and were not introduced to the new roommate until after the move into a semi‑private room. There was no documentation that the resident or family were informed of a right to refuse the move or that written notice explaining the reason for the move was provided. A third resident with cognitive impairment, heart failure, hypertension, heart disease, a fractured hip, and dementia was moved from a rehab hall room to a LTC room. The SW’s progress notes documented a phone call to the resident’s family member with “verbal consent” and a late entry stating that consent was obtained from the spouse to move from the rehab hall to a LTC room that became available, but did not specify the content of the consent or any written notice. The family member reported being told by the SW that the resident was being moved because a new administrator was changing things and moving residents, and that when the family member asked if the move could wait, the SW said no. The family member also reported speaking with a person identifying himself as the Administrator, who stated the current room was meant for rehab and that the resident was moving to the LTC section that day, and that the resident was not the only one being moved. The family member stated the resident was not given a choice of room or roommate, and that staff moved the resident the next day. A fourth resident, cognitively able to make decisions and dependent on staff for ADLs, was admitted to a private room and later moved. The resident’s family member reported receiving a phone call from a person identifying himself as the Administrator, who said the resident was being moved to another room to create an isolation room for potential COVID patients. The family member stated that the SW later said the move had to occur and that the new roommate did not want a camera in the room. The family member reported that the resident was not offered a choice of rooms and was not introduced to the new roommate before the move. There was no documentation of written notice explaining the reason for the move or of any opportunity for the resident to see the new location, meet the new roommate, or ask questions prior to the move. Interviews with staff further clarified the circumstances leading to these deficiencies. The SW stated she had been told by a person identifying himself as the Administrator that residents needed to be moved off the rehab unit to free up rooms for potential rehab residents, and that she was to find rooms on the LTC side or discharge the residents. She reported she was not aware that residents had a choice to move or not, or that they had a choice of roommates, and that she was following instructions. The Administrator interviewed stated he had recently come to the facility, that his temporary license had not yet been approved, and that he needed to move residents to better align acuity for staffing and to keep rehab and LTC residents grouped together. He stated they had obtained permission for the residents to move and that he was not aware residents had the right to decline a room move, although he would expect staff to give residents a choice when able. Across these cases, there was no evidence that residents received written notice of room or roommate changes, were informed of their right to refuse, or were given the opportunity to see the new room, meet the new roommate, and ask questions as required by facility policy and resident rights. The facility also failed to ensure residents’ right to share a room with a roommate of choice. The policy stated that residents have the right to share a room with a spouse, domestic partner, or friend, and that resident preferences are considered when room or roommate changes are proposed. In the described room moves, residents and families reported that no choices of rooms or roommates were offered, and there was no documentation that roommate preferences were solicited or honored. The moves were driven by facility needs such as creating isolation or rehab rooms and redistributing residents by acuity, rather than by resident choice or preference, and were implemented without the written notices and pre‑move opportunities outlined in the facility’s own policy.
Failure to Provide Required Written Discharge Notices and Appeal Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required written discharge notices, including information on appeal rights and bed-hold policies, to three cognitively intact or partially impaired residents who were dependent on staff for ADLs. Facility policy and resident rights documents required that, once admitted, residents have the right to remain in the facility and that any transfer or discharge must meet specific criteria, include proper documentation in the medical record, and be accompanied by written notice detailing the basis for discharge, effective date, new location, appeal rights, and bed-hold policy. Despite these requirements, the facility moved residents off a rehab unit as part of a reconfiguration to group rehab residents together and free up rooms, without issuing the mandated 30‑day or emergency discharge notices. For one resident, progress notes showed the resident and POA were offered placement in a semi‑private LTC room but expressed concerns about room size and setup, and an option to transfer to another facility was offered and accepted. The family member later reported receiving a phone call stating the resident needed to be out within a few days due to reconstruction of the rehab unit and the need to have only rehab residents on that unit, and stated they were not offered a different room in the same facility, did not have a chance to see the new facility, were unaware of resident rights, and did not receive a written discharge notice. The medical record documented a SNF‑to‑SNF transfer and discharge to another facility, but there was no documentation of a written discharge notice or provision of appeal rights and bed‑hold information. For two additional residents, records showed SNF‑to‑SNF transfers and discharges to other facilities, with notes indicating consent obtained and referrals sent, but again without documentation of written discharge notices. Family members reported being told by phone that the residents had to be moved within two days because the rooms were being converted back to rehab use or to make room for an emergency admission, that they felt they had no choice, and that they were not informed of appeal rights. One family member reported the resident’s belongings were hastily packed into boxes, and another reported there was no communication from the discharging facility to the receiving facility regarding medications and pain management. The social workers stated they were instructed by an individual they understood to be the administrator to move residents to free up rooms for rehab residents and believed that written discharge notices were not required for SNF‑to‑SNF transfers, and acknowledged that no 30‑day or emergency discharge notices were issued to these residents.
Improper Use of Mechanical Lift Emergency Release During Resident Transfer
Penalty
Summary
Staff failed to safely transfer a dependent resident using a mechanical lift by inappropriately using the lift’s emergency release button to lower the resident rapidly onto the bed. Facility policy for mechanical lift use required at least two CNAs, selection of an appropriate sling, ensuring the lift was stable and locked, checking attachments and sling fit, and slowly lifting and lowering the resident only as high and as fast as necessary to complete the transfer. The policy specified that residents should be gently supported and slowly lowered to the receiving surface. The resident involved had Parkinson’s disease, Alzheimer’s disease, dementia, anxiety, severe cognitive impairment, and was dependent on staff for transfers per the most recent MDS. Ring camera footage from the resident’s room showed two CNAs placing the resident in a mechanical lift sling to transfer from wheelchair to bed, with one CNA operating the controls and keeping hands on the resident. While the resident was suspended over the bed, the CNA at the controls placed a hand on the red emergency release button, verbally said “Drop him/her?” and then pressed the button, causing the resident to quickly drop onto the bed, which moved on impact, and the resident exclaimed “Oh!” The resident verbally questioned why “drop it” was said. The family member later showed the video to the DON and ADON and stated the method of lowering was unacceptable. The DON confirmed there was no reason to use the emergency release button because the lift battery was charged and there were no reports of malfunction. One CNA reported not hearing the “drop” comment, while the CNA who operated the lift admitted using the emergency release button because the lift lowered residents very slowly and stated they had never been told not to use it for transfers. The ADON and Administrator both stated the emergency release button should only be used in a real emergency when a resident needs to be removed from the lift quickly.
Failure to Treat Residents with Dignity and Respect During Care
Penalty
Summary
Staff failed to treat two residents with dementia and Alzheimer's disease with dignity and respect during the provision of care. In both cases, certified nurse aides (CNAs) did not greet or explain care to the residents, who had significant cognitive impairments and were dependent on staff for activities of daily living. The CNAs used forceful and disrespectful language, exposed the residents unnecessarily, and did not follow the care plans that required clear communication and anticipation of the residents' needs. For one resident, video footage showed a CNA using a mechanical lift to transfer the resident to bed without any greeting or explanation. The CNA removed the resident's clothing, left the resident exposed, and used a scolding tone, repeatedly telling the resident to comply and threatening to call a doctor for a sedative. The CNA also made inappropriate comments about sending the resident out if they did not cooperate. The resident, who was unable to make decisions and had impaired communication, showed resistance, which was misinterpreted by the staff as defiance rather than a lack of understanding. In the second case, another CNA entered a resident's room, turned on the light, and began providing care without speaking to or explaining actions to the resident. The CNA pushed the resident, removed blankets despite the resident's protests, and engaged in an argumentative and mocking exchange. The resident became visibly upset, used foul language, and attempted to defend themselves physically. The CNA continued to provide care in a hostile manner, laughed at the resident, and made dismissive comments, further escalating the resident's distress. Both incidents were captured on video and reported by family members.
Failure to Use Two-Person Assist During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the safety of two residents who were dependent on staff for transfers and at risk for falls by not following its own policy requiring two staff members to assist with mechanical lift transfers. The facility's policy, revised in July 2017, clearly states that at least two nursing assistants are needed to safely move a resident with a mechanical lift. Both residents involved had care plans and Minimum Data Set (MDS) assessments indicating they required two-person assistance for transfers due to conditions such as dementia, Parkinson's disease, and cognitive impairment, and were dependent on staff for activities of daily living. Direct observations and review of video footage provided by family members showed that staff did not consistently use two-person assistance during mechanical lift transfers. In one instance, after both CNAs initially prepared the resident for transfer, only one CNA operated the lift and moved the resident from the wheelchair to the bed, while the other CNA was not assisting and was instead gathering supplies. The resident was left unsupported and swung while suspended in the lift. A similar pattern was observed with another resident, where one CNA operated the lift and moved the resident while the other CNA sat in a chair and did not participate until the resident was being lowered into the wheelchair. Interviews with the involved CNAs and the Director of Nursing confirmed that facility policy requires two staff members for all mechanical lift transfers, with one person operating the controls and the other guiding the resident. The staff acknowledged that they did not follow this protocol during the observed transfers. These actions directly led to the deficiency, as the facility did not provide adequate supervision or follow established procedures to prevent accidents for residents at risk of falls.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to follow established infection control protocols during personal care for two residents who were dependent on staff for activities of daily living and incontinent of bowel and bladder. In both cases, certified nurse aides (CNAs) did not perform hand hygiene before beginning care, donned gloves taken from their pockets, and proceeded to provide care without changing gloves or washing hands between clean and dirty tasks. During care, CNAs handled soiled briefs, performed peri care, and then touched clean supplies, resident bedding, and room equipment without removing soiled gloves or performing hand hygiene. In one instance, a CNA also used a cell phone and handled other items in the resident's environment while wearing the same gloves used for personal care. Interviews with staff confirmed knowledge of the facility's hand hygiene policy, which requires handwashing before and after resident care and glove changes between clean and dirty tasks. However, observations and video evidence showed repeated failures to adhere to these protocols, including not removing gloves or washing hands after providing peri care and before touching other surfaces or equipment. The facility's policy emphasized the importance of hand hygiene to prevent the spread of healthcare-associated infections, but these procedures were not followed during the observed care episodes.
Failure to Honor Resident Choice in Morning Routines
Penalty
Summary
The facility failed to honor the rights of several residents to make choices about their daily routines, specifically regarding their preferred wake-up and get-up times. Observations and interviews revealed that multiple residents were awakened, dressed, and brought to common areas significantly earlier than their stated preferences, with some residents expressing distress or dissatisfaction about being up too early. Staff interviews confirmed the existence of a 'get-up list' or 'early riser list' that directed CNAs to get specific residents up in the early morning hours, regardless of individual preferences, unless a resident was adamant in refusing. Resident records and care plans indicated that residents should be offered the choice to get up in the morning and allowed to refuse, with encouragement for out-of-bed activities aligned with their preferences. Despite these documented directives, residents with varying levels of cognitive impairment and physical assistance needs were observed awake, dressed, and in wheelchairs or specialized chairs in their rooms or dining areas before their preferred times. Several residents directly stated they were not asked about their preferences or were upset about being awakened early, and staff acknowledged following a list rather than individualized routines. The facility's policy on resident rights emphasizes dignity, respect, and self-determination, including support for residents' choices regarding their daily routines. However, the practice of using a predetermined list to manage morning routines resulted in residents being awakened and dressed earlier than they desired, contrary to their care plans and stated preferences. This practice was confirmed through staff interviews and documentation, demonstrating a failure to fully support residents' rights to self-determination and a dignified existence.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During High-Contact Care
Penalty
Summary
The facility failed to ensure that direct care staff consistently utilized Enhanced Barrier Precautions (EBP) and adhered to proper hand hygiene and glove use during high-contact care activities for residents with indwelling medical devices, such as urinary catheters and gastrostomy tubes. Observations revealed that staff did not don required personal protective equipment (PPE), including gowns and face shields, when providing care to residents with these devices, despite clear signage and facility policy indicating the necessity of EBP for such situations. For example, staff were observed assisting a resident with a urinary catheter without wearing gowns or face shields, and performed multiple care tasks, including perineal and catheter care, with soiled gloves and without appropriate hand hygiene between tasks. Additionally, staff demonstrated a lack of understanding regarding the purpose and application of EBP. Interviews with CNAs indicated confusion about when and why EBP bins and PPE were to be used, with some staff believing the precautions were only necessary when residents were acutely ill or "had something going on." This misunderstanding led to inconsistent use of PPE and lapses in infection control practices, such as failing to wash hands after glove removal and before donning new gloves, and not changing gloves between dirty and clean tasks. The residents involved had significant care needs and indwelling devices that required strict adherence to infection prevention protocols. One resident had a suprapubic catheter and required EBP during high-contact care, while another had a gastrostomy tube and was dependent on staff for all activities of daily living. Despite these needs, staff did not follow established protocols for EBP and hand hygiene, as evidenced by multiple observed care episodes and staff interviews. The Director of Nursing confirmed that staff were expected to use EBP for residents with relevant signage and devices, but observations and interviews showed this was not consistently practiced.
Dish Machine Temperature and Kitchen Cleanliness Deficiencies
Penalty
Summary
The facility failed to ensure that the dish machine in the kitchen operated at the correct temperature and that equipment and surfaces were kept clean, potentially affecting all 113 residents who received meals prepared in the facility. Observations revealed that the dish machine's wash and rinse cycles only reached 100 degrees Fahrenheit, below the manufacturer's requirement of 120 degrees Fahrenheit. The Dietary Manager (DM) did not document the wash and rinse temperatures, only the results of the sanitation test strips, and was unaware of how long the machine had been operating at the incorrect temperature. The Administrator and DM confirmed the lack of temperature documentation, which could have identified the issue sooner. Additionally, the kitchen was found to have several cleanliness issues. The ventilation filters and exterior hood had a thick layer of grease, the fryer contained food particles, and the oven and grill had a build-up of grease and debris. The dish machine area had dried splatters, a black substance, and a warped surface, while the floors had dried spills, food, trash debris, and a dark build-up. The Registered Dietitian (RD) was unaware of the dish machine's temperature issue and the unclean conditions, having only conducted one kitchen sanitation inspection since starting at the facility.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, as observed during multiple instances. For Resident 68, who was severely cognitively impaired and required assistance with eating, staff members were observed standing while assisting with meals, contrary to the facility's policy that emphasizes sitting to ensure dignity. This occurred on multiple occasions with different staff members, including a CNA, MDS Coordinator, and a CMT, who all stood while feeding the resident, citing reasons such as readiness to assist others or simply not knowing the policy. Resident 98, also severely cognitively impaired, experienced a similar issue where a CMT stood while offering food, then moved to assist another resident without sitting. Additionally, Resident 88, who refused the meal served, was not promptly offered an alternative. It took 48 minutes for the resident to receive a grilled cheese sandwich after initially refusing the fish fillet, potatoes, and bread. During this time, the resident was observed looking around at others eating, indicating a lack of timely response to her needs. Furthermore, Resident 102, who had intact cognition, was the last to be served at a table where others had already started eating. This delay made the resident feel unloved, highlighting the lack of continuous dining service. The facility's Director of Nurses acknowledged the expectation for all residents at a table to be served simultaneously, although there was no specific policy addressing this. These observations indicate a failure to adhere to the facility's dining assistance policy, affecting the dignity and dining experience of the residents involved.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to implement weight loss interventions and provide meal encouragement for a resident identified as R95, who was reviewed for nutrition among 30 sample residents. R95, who was severely cognitively impaired with diagnoses of malnutrition, Alzheimer's disease, and primary open-angle glaucoma, experienced significant weight loss. The facility's policy on nutrition and unplanned weight loss required staff and physicians to identify and monitor interventions based on the resident's condition. However, R95's care plan did not include a specific plan for diet or nutrition, despite the resident's significant weight loss and malnutrition diagnosis. Observations revealed that R95 was not consistently provided with the prescribed fortified diet and chocolate milk, which were part of the interventions to address the resident's nutritional needs. During multiple meal observations, R95 did not receive chocolate milk or fortified items, and there was a lack of encouragement from staff to consume meals. For instance, during breakfast and lunch observations, R95 was served meals without the prescribed chocolate milk, and staff failed to encourage or assist the resident in eating, resulting in poor intake. Interviews with staff, including the Director of Nursing (DON), Certified Nurse Aides (CNAs), and the Registered Dietitian (RD), highlighted a lack of awareness and adherence to the prescribed dietary interventions for R95. The DON acknowledged the resident's significant weight loss and the need for chocolate milk at meals, yet it was not consistently provided. The RD, who was new to the facility, was aware of the weight loss but not of the lapses in providing the prescribed diet. The facility's failure to implement and monitor the necessary nutritional interventions for R95 had the potential to cause further weight loss.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain the cleanliness and proper closure of dumpster lids in the dumpster area adjacent to the kitchen's rear exit hall, which serves 115 census residents. The facility's policy, revised in April 2006, mandates that all garbage and rubbish containing food waste be kept in containers with tight-fitting lids, which must be closed when not in continuous use. During an observation with the Dietary Manager, it was noted that the lids of two garbage dumpsters were open, exposing numerous plastic garbage bags. Additionally, two plastic garbage bags were found on the concrete next to the dumpsters, which the Maintenance Assistant placed inside the dumpsters without closing the lids. Further observations revealed that the lids remained open on subsequent days, and food debris spillage was noted on the outside of the recycling dumpster. The Administrator acknowledged that the lids should be closed each time trash is placed inside but mentioned the difficulty in ensuring compliance across all departments. This failure to adhere to the facility's policy on garbage disposal has the potential to attract rodents and other pests, posing a risk to the facility's environment.
Failure to Submit DCRA MDS Assessment Timely
Penalty
Summary
The facility failed to ensure timely submission of a discharge return anticipated (DCRA) Minimum Data Set (MDS) assessment for one resident, identified as Resident 6, out of a sample of 30 residents. According to the facility's policy, resident assessments must be submitted in accordance with federal and state submission timeframes. The October 2023 Resident Assessment Instrument (RAI) Manual specifies that the DCRA assessment should be transmitted within 14 calendar days of the MDS Completion Date. However, a review of Resident 6's electronic medical record revealed that the DCRA MDS assessment, with an Assessment Reference Date of 09/15/24, was in a completed status but not in an accepted status, indicating it was never submitted for processing. During an interview, the MDS Coordinator acknowledged the oversight, confirming that the assessment was not added to a batch for submission. This failure to submit the assessment in a timely manner had the potential to adversely affect care planning and care provision or payment to other facilities for any resident lacking a transmitted discharge assessment. The facility's policy, last reviewed in July 2017, assigns the responsibility of ensuring timely submission of assessments to the assessment coordinator or designee, but this protocol was not followed in this instance.
Deficiency in Developing Comprehensive Care Plans for Psychoactive Medications
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan with measurable goals and plans for two residents who were prescribed psychoactive medications. For one resident, the care plan did not include goals or interventions for the antipsychotic medication, and there was no identification of the target behavior being monitored for the psychoactive medications. The resident had been admitted with diagnoses including dementia, insomnia, and depression, and was prescribed multiple psychoactive medications without a clear care plan to monitor their effects. For the second resident, the care plan included a goal for improved sleep but lacked baseline data to measure the effectiveness of the hypnotic medication. Additionally, the care plan for antipsychotic medication did not establish a baseline for therapeutic effects, making the goal unmeasurable. The resident was admitted with similar diagnoses and was prescribed several psychoactive medications. The Director of Nursing acknowledged the absence of shift documentation to establish baselines or measure decreases in symptoms.
Deficiencies in Toileting Assistance and Catheter Order Management
Penalty
Summary
The facility failed to provide timely toileting assistance to a resident with severe cognitive impairment, leading to discomfort and distress. The resident, who required maximum assistance with toileting, was observed requesting to use the bathroom multiple times over a 19-minute period without receiving assistance. During this time, the resident was visibly distressed and crying, indicating significant discomfort. The delay in assistance was attributed to the limited availability of CNAs, as they were occupied with other residents. Additionally, the facility did not have an order in place for the use of an indwelling catheter for another resident with moderately impaired cognition and a history of prostate cancer. This resident was observed with a catheter bag, but the necessary orders for catheter care were missing from the electronic medical record. The absence of these orders meant that catheter care was not documented, and the staff was unaware of the specific requirements for the catheter, such as size and care instructions. Interviews with staff, including an LPN and the DON, revealed that the lack of catheter orders was due to an oversight in transferring orders from the urology department into the facility's system. This oversight resulted in a lack of documentation for catheter care, which is essential for preventing complications such as urinary tract infections. The DON acknowledged the need for proper orders to ensure appropriate catheter management.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure documented indications for the use of psychotropic medications and to monitor their efficacy for two residents. Resident 61 was admitted with diagnoses including dementia, hypertension, and insomnia. The resident was prescribed quetiapine, an atypical antipsychotic, without a documented diagnosis or behaviors justifying its use. Additionally, there was no monitoring of the medication's efficacy or target symptoms in the resident's medical records. Interviews with the Assistant Director of Nursing revealed that the medication was prescribed due to nighttime yelling, but this behavior was not documented. Resident 94, admitted with dementia, insomnia, and depression, was prescribed multiple psychoactive medications, including Ambien, Lorazepam, Mirtazapine, Modafinil, Prozac, Trazodone, and Vraylar. Despite having orders for behavior monitoring and non-pharmacological interventions, there was no documentation of monitoring target behaviors for medication efficacy in the resident's records. The Director of Nursing confirmed that behaviors should be monitored each shift, but this was not reflected in the documentation. The lack of documentation and monitoring for both residents indicates a failure to adhere to the facility's policy on psychotropic medication use. This oversight could potentially affect the ability of physicians to prescribe the lowest effective dose of medication, as there is no recorded evidence of the medications' necessity or effectiveness.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences were obtained and honored, which had the potential to affect the resident's nutritional status. The resident, who was cognitively intact and had a history of heart failure, atrial fibrillation, and coronary artery disease, was on a mechanically altered diet. Despite the care plan indicating that food preferences should be catered to, the dietary interview sections for beverage preferences, snacks, and food likes/dislikes were left blank. This oversight led to the resident being served meals that included items she disliked, such as scrambled eggs, which she received repeatedly for breakfast. Observations and interviews revealed that the resident expressed dissatisfaction with the repetitive nature of her meals and the inclusion of disliked items. The dietary manager, responsible for the initial assessment of food preferences, was unaware of the resident's dislikes and had not communicated with her regarding her preferences. The registered dietitian also confirmed that she was not informed about the resident's food preferences not being obtained. The administrator acknowledged the oversight when informed that the resident's dislikes were not listed on the meal ticket, leading to the repeated serving of scrambled eggs, which the resident did not like.
Failure to Provide Proper Transfer Notices
Penalty
Summary
The facility failed to provide proper written transfer or discharge notices to three residents who were transferred to the hospital. The facility's policy requires that residents and their representatives receive a written notice that includes the reason for transfer, the place of transfer, and information about the appeals process. However, this policy was not followed for three residents, leading to deficiencies in communication and documentation. Resident 6 was transferred to the hospital due to a change in the position of a feeding tube and associated vomiting. Although a transfer notice was created, it lacked specific details such as the recipient of the document, the destination of the transfer, and the specific reason for the transfer. Interviews with staff revealed that the notice was not provided to the resident or their representative, and there was no documentation of the notice being mailed. Resident 16, who was severely cognitively impaired, was transferred to the hospital with a urinary tract infection and sepsis. The transfer notice did not include the date of transfer, the reason for transfer, the location, or an explanation of the appeals process. Similarly, Resident 54, who was cognitively intact, was transferred due to cardiac issues. The transfer notice for this resident also lacked essential information. Interviews with staff indicated a lack of understanding and adherence to the facility's policy on providing written notices, contributing to the deficiency.
Failure to Provide Complete Bed Hold Notice During Emergent Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice with all required information to a resident or their representative during an emergent transfer to the hospital. The facility's policy mandates that residents or their representatives receive written information about bed-hold policies at least twice: in advance of any transfer and at the time of transfer, or within 24 hours if the transfer is an emergency. However, in the case of one resident, the facility did not include information regarding the financial commitment, such as the daily cost, in the bed hold notice provided during an emergency transfer. The resident in question was admitted with multiple medical diagnoses, including cerebral infarction and acute respiratory failure, and was transferred to the hospital due to a change in a feeding tube's position with associated vomiting. The facility's documentation showed that the social services department attempted to contact the resident's representative to discuss the transfer form, which included the bed hold notice, but there was no documentation of the form being mailed or received. Interviews with facility staff, including an LPN and the DON, confirmed that the bed hold notice did not include the necessary financial information, and there was no evidence of the notice being mailed promptly.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to serve food to residents at an appetizing temperature. Observations, interviews, and record reviews revealed that residents who ate meals in their rooms reported that the food was cold when served most of the time. The facility had a census of 115 residents at the time of the survey.
Failure to Inform Residents of Non-Covered Service Charges
Penalty
Summary
The facility failed to inform five residents or their representatives about the potential charges for respiratory therapy services that were not covered under Medicare/Medicaid or by the facility's per diem rate. This deficiency was identified during interviews and record reviews, where it was found that these residents were charged for the services without prior notification. The review included 16 sampled residents, and the facility census was 115.
Failure to Administer Prescribed Medications Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received the appropriate medications as ordered by the physician to treat a urinary tract infection (UTI). The Assistant Director of Nursing (ADON) received a verbal order from the resident's physician to administer Florastor, a probiotic, and later to discontinue Macrobid, an antibiotic, and start Cipro, another antibiotic. However, these orders were not entered into the resident's medication administration record, resulting in the resident not receiving the necessary medications. The resident, who had a history of Alzheimer's disease, type two diabetes with diabetic nephropathy, hemiparesis, hemiplegia, and aphasia, was at risk for activities of daily living and mobility decline. The resident's condition required substantial assistance from staff for toileting and transfers. Despite the physician's orders and the resident's medical needs, the failure to administer the prescribed medications led to the resident being hospitalized with vomiting, an abnormal urine analysis, possible pneumonia, and a diagnosis of pyelonephritis, a severe kidney infection. Interviews with the ADON and the Director of Nursing (DON) revealed that the ADON had delegated the task of entering the Cipro order to another nurse, which was not completed, and the DON expected immediate notification of abnormal lab results. The resident's physician was unaware that the resident did not receive the prescribed medications and emphasized the importance of administering the correct antibiotic to prevent serious infections like pyelonephritis. The oversight in medication administration and communication contributed to the resident's hospitalization.
Failure to Maintain Licensed Administrator
Penalty
Summary
The facility failed to comply with state laws by not having a licensed nursing home administrator in place, which had the potential to affect all 117 residents. The facility's policy required a licensed administrator to oversee daily operations, and in the event of a license expiration, a fully licensed administrator was to be appointed within 10 days. However, the administrator's temporary emergency license expired, and he continued to perform duties similar to those of an administrator, including issuing a discharge notice, which he acknowledged was invalid due to his lack of a valid license. The interim administrator was expected to start on a specific date but was not present in the facility for a full day after her initial entry. The Regional President of Operations was aware of the expired license and acknowledged that the administrator did not meet the guidelines for license application review. The administrator believed the facility had a 10-day window to appoint a licensed administrator, but this was not adhered to, leading to a lapse in compliance with state regulations.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, as required by their policy. The facility, with a census of 117, did not have an IP for some time, and the Director of Nursing (DON) only recently obtained her IP certification. During this period, there was no tracking of infections or antibiotics, and although the DON noticed a trend in urinary tract infections, she was unaware of which residents were affected or the measures being taken. The Administrator acknowledged the absence of an IP until the DON's recent certification and expressed an expectation for infection tracking within the facility.
Failure to Follow Planned Menu and Serve Correct Portions
Penalty
Summary
The facility failed to adhere to the planned menu reviewed by the Registered Dietician, resulting in discrepancies between the menu and the meals served to residents. On multiple occasions, the meals served did not match the menu items, and the correct serving sizes were not provided. For instance, on one occasion, the lunch menu was supposed to include chicken rice soup, but it was not prepared, and no substitute was available. Instead, a turkey burger was served, which many residents found unappealing due to its appearance. Additionally, the dinner menu was supposed to include a garden salad and roasted Brussels sprouts, but these items were not served, nor were any equivalent substitutions provided. The dietary staff also failed to serve consistent portion sizes, as observed with the Jello served to residents, which varied in quantity and was melted. A resident expressed dissatisfaction with receiving only half a BLT sandwich and noted that the kitchen often ran out of food or served items different from the menu. The Dietary Manager admitted to making adjustments to the menu based on availability and resident preferences, such as substituting homemade potato chips with store-bought ones, without ensuring that the nutritional requirements were met. The Registered Dietician was unaware that the facility was not following the approved spreadsheets for meal preparation, which were intended to meet the residents' dietary needs, including necessary vitamins. The Administrator assumed that the spreadsheet menus met the requirements and should be followed by the Dietary Manager. However, the lack of communication and adherence to the planned menu led to residents not receiving the intended meals, impacting their nutritional intake.
Inadequate Discharge Notice and Documentation for a Resident
Penalty
Summary
The facility failed to issue an appropriate discharge notice for a resident, resulting in several deficiencies. The discharge notice lacked a proper discharge location and did not include the necessary information for the resident's right to appeal, such as the contact details for the state entity handling appeal requests. Additionally, the facility did not ensure that the resident's physician documented in the medical record the specific needs that the facility could not meet, nor did it provide an explanation of what the facility had attempted to do to meet those needs. The resident, who had severe cognitive impairment and exhibited behaviors that endangered themselves and others, was discharged without a clear plan or proper documentation. The resident's Durable Power of Attorney (DPOA) was informed of the discharge decision via a phone call and received the discharge notice by email. The facility's social worker attempted to refer the resident to a psychiatric facility, but the referral was not accepted, and the DPOA was told it was their responsibility to find alternative facilities. The administrator admitted to not having the correct appeals information on the discharge notice and was unaware of the requirement for physician documentation in non-emergency discharge cases. This was the first time the administrator had issued a discharge notice.
Failure to Maintain Kitchen Faucet
Penalty
Summary
The facility failed to maintain the water faucet in the food preparation area of the kitchen, resulting in a continuous flow of water at approximately half capacity. The issue was first reported by the Dietary Manager on 7/1/24, who submitted a work order for a leaking sink that would not shut off. The Maintenance Director marked the issue as resolved, but the problem persisted, as the faucet continued to run without stopping. A subsequent work order was submitted on 8/13/24 for the lack of hot water in the same sink, which was also marked as resolved by the Maintenance Director. However, the faucet continued to run continuously, as observed on 8/20/24 and 8/21/24. Interviews with the Maintenance Director and the Dietary Manager revealed a communication breakdown, as the Maintenance Director claimed not to have received a work order for the running faucet, while the Dietary Manager confirmed submitting multiple requests. The Administrator was unaware of the ongoing issue and expected the maintenance department to address it upon receiving a work order. This deficiency highlights a failure in the facility's maintenance processes, as the problem was not effectively communicated or resolved, leading to a persistent issue with the kitchen faucet.
Delayed X-ray and Pain Management for Resident After Fall
Penalty
Summary
The facility failed to provide timely care and treatment for a resident who sustained a fall and was in pain. After the fall occurred at 2:15 A.M., the responsible party opted for a mobile x-ray instead of hospital transport. A STAT mobile x-ray was ordered at 3:00 A.M., but the x-ray provider did not arrive until 10:30 A.M. The results were sent to the facility at 10:50 A.M., but staff delayed communicating these results to the physician until 1:30 P.M. The resident was eventually sent to the emergency room and diagnosed with a fractured right shoulder. Additionally, the facility did not follow the emergency room discharge orders for pain medication, delaying appropriate pain management until the resident was seen by their physician 12 days after the injury. The facility census was 117.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately address significant weight loss in three residents, as identified through observation, interview, and record review. Resident #2 experienced a 5.9% weight loss over five months, Resident #3 had a 9.3% weight loss in three months, and Resident #4 suffered a 17% weight loss over seven months. The facility did not notify the physician or registered dietician about these weight losses, nor did it implement or evaluate the effectiveness of interventions for these residents. Specifically, for Resident #4, the facility failed to communicate and implement the interventions recommended by the Registered Dietician to prevent further weight loss. The facility's census at the time was 117.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed by surveyors. The kitchen floors were not kept clean, with food, debris, and rodent feces present. Additionally, surfaces of kitchen equipment were found to have rodent feces. The staff did not label and date food items when opened, leading to improper food storage. Furthermore, compromised food items, including ice cream and apples, were not discarded appropriately. The facility had a census of 117 residents at the time of the survey.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents in the kitchen. This deficiency was identified through observation and interview during a survey. The facility had a census of 117 residents at the time of the survey.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate services for a resident diagnosed with dementia, which affected the resident's well-being and that of others. Despite identifying that the resident exhibited behaviors impacting themselves and other residents, the facility did not evaluate or implement further approaches to address these care needs. The resident experienced an increase in behaviors, leading to the administration of anti-anxiety intramuscular medication and psychotropic medication without attempting alternative interventions first. Although the resident's physician ordered a psychiatric consultation due to the increase in behaviors, the facility did not schedule this consultation. Consequently, the resident continued to exhibit behaviors, resulting in an increased administration of psychotropic medications by staff as an intervention.
Delayed X-ray and Pain Management for Resident After Fall
Penalty
Summary
The facility failed to provide timely care and treatment for a resident who sustained a fall and was in pain. The resident, who had severe cognitive impairment and required maximum assistance for transfers, fell at 2:15 A.M. and complained of right shoulder and arm pain. A STAT mobile x-ray was ordered at 3:00 A.M., but the x-ray provider did not arrive until 10:30 A.M. The facility did not administer pain medication or alternative interventions for the resident's pain during this time. The x-ray results, which showed a fractured right shoulder, were not communicated to the physician until 1:30 P.M., leading to a delay in sending the resident to the emergency room for further evaluation. The facility also failed to follow the emergency room discharge orders for pain management. After the resident returned from the hospital with instructions to use a lidocaine patch for pain, the facility did not apply the patch for 12 days. The Medication Administration Record (MAR) showed no order for the lidocaine patch until 7/16/24, despite the hospital's discharge orders. This oversight resulted in the resident experiencing prolonged pain from the fractured shoulder. Interviews with facility staff and representatives from the mobile x-ray provider revealed communication breakdowns and a lack of awareness regarding the x-ray results. The facility did not have a policy for reporting x-ray results or expectations for following discharge instructions. Additionally, the facility's contract with the x-ray provider did not include phone call notifications for positive fracture results, and the text message alerts were sent to former management personnel who were no longer employed at the facility.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in three residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Resident #2 experienced a 5.9% weight loss over five months, Resident #3 had a 9.3% weight loss in three months, and Resident #4 suffered a 17% weight loss in seven months. The facility did not notify the physician or the registered dietician about these weight losses, nor did they implement or evaluate interventions to address the issue. Resident #2, who had severe cognitive impairment and a diagnosis of malnutrition, was observed not being assisted with meals and was left without food when he/she did not come out for lunch. The care plan did not include interventions for when the resident missed meals, and there was no documentation from the dietician or physician regarding the weight loss. Similarly, Resident #3, also with severe cognitive impairment, was not assisted with meals and experienced a significant weight loss without weekly weights being documented or the physician being notified. Resident #4, who was at risk for malnutrition, was not provided with fortified foods as ordered, and there was no follow-up from the dietician or notification to the physician about the continued weight loss. The dietary manager was unaware of the resident's fortified diet order, and the registered dietician assumed nursing was following through with recommendations without verification. The facility's staff, including the Unit Manager and DON, failed to ensure accurate weight monitoring and communication of weight loss to the physician, contributing to the deficiency.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and kitchenette areas, leading to a health deficiency. Observations revealed that the kitchen floors and equipment surfaces were contaminated with rodent feces, and food items were improperly stored, labeled, and dated. Specific issues included a refrigerator containing unlabeled and undated food items, such as a cup of liquid from a fast-food restaurant, a plastic container with an unidentified green liquid, and a partially full container of ice cream with ice buildup. Additionally, withered apples and open food packages were found in a cabinet. The main kitchen had numerous black pellets resembling rodent feces on a stainless steel preparation table, under the steam table, and around a large trash can. Food particles and rodent feces were also found under the stove, beverage dispenser, and behind the refrigerator. Interviews with facility staff, including the Dietary Manager, Maintenance Director, Registered Dietician, and Medical Director, confirmed awareness of the rodent problem and the unsanitary conditions in the kitchen. The Dietary Manager acknowledged the issue of mice in the kitchen and reported it to the Administrator and Maintenance Director. The Maintenance Director and Registered Dietician both noted the need for cleanliness to prevent rodent infestation, with the Dietician conducting monthly inspections and sharing reports with the administration. The Medical Director emphasized the expectation for the kitchen to be cleaned after every meal and at the end of the day. Despite these acknowledgments, the facility's policies on sanitization and pest control were not effectively implemented, contributing to the deficiency.
Failure to Inform Residents of Non-Covered Respiratory Therapy Charges
Penalty
Summary
The facility failed to inform five residents or their representatives about respiratory therapy services that were not covered under Medicare/Medicaid or by the facility's per diem rate before these services were provided. This deficiency was identified during interviews and record reviews, revealing that residents were charged for services without prior notification. The facility did not have a policy in place for the respiratory therapy department or to outline the responsibilities of the respiratory therapist, contributing to the lack of communication regarding non-covered services. Resident #5, who was a private pay and Medicare Part B recipient, received respiratory therapy services without being informed of the charges that would not be covered by Medicare. The resident's power of attorney was unaware of these charges until receiving a bill, which was later credited by the facility. Similarly, Resident #13, who was on hospice care, received respiratory therapy services without the responsible party's knowledge, under the assumption that all care was provided by the hospice company. The facility's billing statements showed significant amounts waiting to be billed to Medicare, with the remainder expected to be covered by the resident. The facility's failure to notify residents or their representatives of non-covered charges was further evidenced in the cases of Residents #14, #15, and #16. These residents, who were either on hospice or had a combination of Medicare, Medicaid, and private insurance, received respiratory therapy services without prior notification of potential charges. Interviews with the residents' representatives revealed a lack of awareness about the services and the associated costs. The respiratory therapist and business office manager confirmed that no consent was obtained for non-covered charges, and there was confusion about the notification process for these services.
Failure to Provide Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary oral hygiene care for five residents who were unable to perform their own activities of daily living. Observations and interviews revealed that these residents had food particles and white substances built up on their teeth, indicating a lack of proper oral care. The facility's policy required staff to assist residents with oral hygiene, but there was no specific care plan for oral hygiene for these residents, and the oral status sections in their assessments were left blank. Resident #1, diagnosed with Alzheimer's disease and depression, required supervision for oral hygiene but had no care plan addressing this need. Resident #2, with multiple diagnoses including heart disease and dementia, reported missing electric toothbrushes and had not received assistance with brushing teeth for a long time. Resident #3, with diabetes and Parkinson's disease, needed help with oral care but did not receive it, as evidenced by unused and dirty oral care supplies in their bathroom. Interviews with staff, including a Licensed Practical Nurse and a Certified Nurse Aide, indicated that agency staff were not consistently providing the required oral hygiene care. The Assistant Director of Nursing acknowledged receiving complaints about oral hygiene and had attempted to in-service staff, but faced challenges with agency staff compliance. The Director of Nursing confirmed that oral hygiene should be performed according to policy, but noted difficulties with agency staff completing all required tasks, attributing the issues to newer problems identified with agency staff.
Failure to Follow Menu and Serve Correct Portions
Penalty
Summary
The facility failed to ensure that the planned menu, reviewed by the Dietary Consultant, was followed, and the correct serving sizes were provided to residents. Observations revealed that the dining room was full of residents, and staff served meals in a random order, causing some residents to watch others eat while waiting for their meals. The menu items were not served as planned; for instance, the ham was served without gravy, and the pieces of ham varied in size. Additionally, staff did not use measured scoops to serve food, and there was a lack of drinks and sugar available for residents. Further observations showed that some residents did not receive the chicken and rice soup as the dietary staff claimed they were out, despite a stock pot of soup being available in the kitchen. The turkey burgers were served as half portions on a piece of bread, and potato wedges were served by hand without using tongs or measuring tools. The apple slaw was missing from the serving line, and the dietary aide expressed confusion and agitation when questioned about the soup shortage. Interviews with dietary staff and consultants revealed a lack of recipes in the kitchen and inconsistencies in menu planning and execution. The Registered Dietitian and Medical Director expected the dietary staff to follow menus and recipes, maintain cleanliness, and provide timely service. However, the facility was without a dietary manager, leaving the Administrator responsible for overseeing the dietary staff. The Dietary Consultant noted that the current menus were difficult to follow due to being pieced together by a previous manager, and the dietary staff should have been following recipes to ensure proper meal preparation.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food to residents at an appetizing temperature, as observed through interviews and record reviews. Residents who ate meals in their rooms reported that the food was often cold when served. The facility did not provide a policy for food temperatures upon request, and the dietary cook's job description required recording food temperatures for each meal. However, the facility's Tray Line Food Temperatures records showed that no food temperatures were taken for several meals over multiple days, indicating a lack of adherence to the policy that hot foods should be 135 degrees Fahrenheit or greater and cold foods should be 41 degrees Fahrenheit or less. Observations on a test tray revealed that the food was not served at the appropriate temperatures, with a turkey burger on a bun at 92 degrees Fahrenheit and potato wedges at 90 degrees Fahrenheit. Additionally, the tray was missing several items listed on the menu, such as chicken and rice soup, apple slaw, and dessert. Interviews with residents confirmed that the food was usually cold when received in their rooms. The dietary consultant stated that food temperatures should be taken before meals are served, and the Administrator acknowledged the issue, noting that the Dietary Manager had recently quit, leaving her to oversee the kitchen until a new manager was hired.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement a policy for Enhanced Barrier Precautions (EBP) to reduce the transmission of multi-drug resistant organisms (MDROs) among residents. The existing policy for isolation and transmission-based precautions did not address EBP, including criteria for placement, required personal protective equipment (PPE), or whether residents needed to be in isolation or private rooms. This deficiency was observed in the care of four residents who met the criteria for EBP due to conditions such as indwelling catheters, pressure ulcers, and feeding tubes. Interviews with staff, including the Director of Nursing, Licensed Practical Nurses, Certified Nurse Aides, and the Assistant Director of Nurses, revealed a lack of awareness and understanding of EBP. Staff members were not consistently using PPE when providing care to residents who required EBP, and there was no signage or clear instructions on when and why PPE should be used. Some staff members were unaware of what EBP meant, and there was no facility policy to guide them in implementing these precautions. Observations of the residents' rooms showed a lack of signage indicating the need for PPE and the absence of PPE supplies readily available for staff. Residents with indwelling catheters and pressure ulcers did not have care plans addressing EBP, and there were reports of staff not adhering to infection control practices, such as wearing gloves when handling urinary catheters. The Director of Nursing acknowledged the absence of a specific EBP policy, relying instead on the general contact isolation policy, which was insufficient to address the specific needs of residents requiring EBP.
Rodent Infestation in Facility Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents in the kitchen. Observations revealed numerous instances of rodent feces on various surfaces, including a stainless steel preparation table, a cart with plate covers, under the main steam table, and around a large trash can. Food particles and rodent feces were also found under the stove, beverage dispenser, and on the floor behind the refrigerator. The Dietary Manager acknowledged the ongoing issue with mice, which had been reported to the Administrator and Maintenance Director. Despite efforts to keep the kitchen clean, a shortage of staff was noted. Interviews with the Maintenance Director, Registered Dietician, and Administrator confirmed awareness of the rodent problem. The Maintenance Director mentioned that the pest control company had been involved, placing traps and spraying outside, but the issue persisted, particularly in the past three weeks. The Registered Dietician's monthly inspections consistently reported a dirty kitchen with mouse droppings, and these reports were shared with key facility personnel. The Administrator attributed the problem to nearby construction and stated that treatment efforts were ongoing. The Medical Director emphasized the importance of maintaining a clean kitchen to prevent rodent infestations.
Medication Mismanagement in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications were not left in resident rooms without proper orders for self-administration, affecting three residents out of a sample of thirteen. Resident #2 was found with a container of Nystatin Powder in their bathroom, labeled with another resident's name, and the resident reported that staff occasionally applied the powder but had not done so recently. Additionally, an opened bottle of artificial tears with no label or resident name and an expired date was found in a shared bathroom, with the Assistant Director of Nursing unable to identify the owner of these items. Resident #4's room contained an opened bottle of Clear Eyes eye drops and a container of Mineral Cream, both without proper labeling or orders for use, and the resident was unaware of how these items came to be in their room. Resident #10 was observed with a tube of triple antibiotic ointment labeled with another resident's name, and there was no order for its use. The Director of Nursing confirmed that medications should not be left in resident rooms without orders for self-administration and that staff should only use medications with the correct resident name on the label.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate services to a resident diagnosed with dementia, leading to a deficiency in care. The resident exhibited behaviors affecting themselves and others, but the facility did not evaluate or implement further approaches to address these behaviors. Instead, the resident was administered anti-anxiety and psychotropic medications without attempting alternative interventions first. Despite an order for a psychiatric consultation due to increased behaviors, the facility failed to schedule the consultation, resulting in continued behavioral issues and increased medication administration. The resident's care plan included interventions for cognitive impairment and psychosocial behavior, but these were not effectively implemented or adjusted in response to the resident's needs. The resident's behaviors, such as verbal and physical aggression, exit-seeking, and agitation, were documented, but there was a lack of documentation regarding alternative interventions before administering medications. The facility's policies emphasized non-pharmacological interventions and the involvement of the interdisciplinary team, but these were not adequately followed. Interviews with facility staff revealed a lack of communication and follow-through regarding psychiatric consultations. The former DON had been working on a contract with psychiatry, but after their departure, no further actions were taken. The Medical Director acknowledged that medications should be reviewed for behaviors and alternative interventions should be used before administering intramuscular medications. The facility's failure to adhere to its policies and ensure timely psychiatric consultation contributed to the deficiency in care for the resident.
Unlicensed Acting Administrator in Facility
Penalty
Summary
The facility failed to comply with state laws by not designating a person as an administrator who is currently licensed in the state as a nursing home administrator. This deficiency was observed during a survey when it was noted that the facility did not have a current administrator's license displayed, although the facility's license to operate and various association memberships were visible. The acting administrator, who had been in the role for about a week, admitted during an interview that he did not hold a license to be an administrator in the state of Missouri. He also acknowledged that he had not contacted the state licensing board or the state regulatory agency to obtain a temporary license, nor was he or his company aware that such a temporary license could have been applied for prior to his appointment as acting administrator. This oversight had the potential to affect all 118 residents of the facility.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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