Strafford Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Strafford, Missouri.
- Location
- 505 West Evergreen, Strafford, Missouri 65757
- CMS Provider Number
- 265656
- Inspections on file
- 33
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Strafford Care Center during CMS and state inspections, most recent first.
Staff failed to follow approved menus and portion sizes, leading to residents routinely receiving smaller portions than specified. Observations showed a dietary staff member serving fewer chicken tenders and reduced amounts of pureed vegetables than listed on the menu, despite facility policies requiring use of standardized recipes and diet spreadsheets approved by the RD. Two cognitively intact residents reported consistently small portions, including meals consisting only of a chicken pot pie or a hotdog with a very small amount of sauerkraut. Dietary staff described "eyeballing" food quantities, using smaller scoops than required, and being instructed by the Dietary Manager to reduce portions when there was not enough food prepared. CNAs, an LPN, and a CMT corroborated that residents, especially those on puree diets and those on a particular unit, often received insufficient food and smaller dessert portions, while leadership acknowledged that staff were expected to serve the quantities specified on the menus.
The facility failed to honor resident choice and self-determination regarding bathing by not consistently providing showers as expected and as important to residents. Several cognitively intact and impaired residents with significant ADL needs, incontinence, and mobility limitations reported going one to two weeks or longer between showers, despite stating they wanted and were supposed to receive two showers per week. Documentation showed prolonged gaps between showers without recorded refusals, while staff acknowledged ongoing problems with shower provision, short staffing, unclear assignment of shower responsibilities, and confusion over whether to document showers on paper or in the EMR. Leadership confirmed that showers should be offered twice weekly and that lack of documentation or "not applicable" entries meant showers were not given, yet the DON had not been reviewing shower records, resulting in residents feeling dirty, embarrassed, neglected, and concerned about body odor.
A resident with dementia and a care plan allowing floor scooting was on the floor near the nurses’ station, as per their documented behavior plan. CNAs attempted to guide the resident out and had the wheelchair available, but when the resident was asked if they wanted to get up, the resident refused. An RN who did not usually work on that unit insisted the resident be placed in the wheelchair, stated they did not care what the resident wanted, and, with a CNA’s help, lifted the resident into the chair despite the resident’s resistance. The resident then struck the RN. Multiple staff, including CNAs, CMTs, the DON, and the Administrator, confirmed that the resident was care planned to scoot on the floor and that forcing a transfer to a wheelchair against the resident’s wishes violated the resident’s rights to dignity and self-determination.
A resident with post-stroke hemiplegia, chronic pain, COPD, and dependence on staff for transfers had an active physician order for a custom wheelchair to improve positioning and comfort, but the facility failed to follow through on obtaining it. The resident reported significant back pain from prolonged bedrest, could tolerate the current wheelchair for only brief periods due to discomfort, and largely remained in bed. The therapy director described completing evaluations and wheelchair forms and placing them in physician folders, but there was no documentation that the forms were processed or that a DME supplier completed the custom wheelchair order. The DON, social services director, business office manager, and administrator gave inconsistent accounts of who was responsible for ordering and tracking the wheelchair, and none had paperwork showing progress on the order. Despite a detailed DME policy and an order for a custom wheelchair, the facility did not ensure the resident received the ordered equipment or that staff reasonably accommodated the resident’s mobility and seating needs.
A resident with dementia and severe cognitive impairment, who preferred family involvement in care discussions, was moved from one room on a special care unit to another to free a private room for an anticipated private-pay admission. Staff, including housekeeping, carried out the move without prior notification to the resident or the resident’s representative, and there was no documentation in the medical record of any discussion or notice regarding the room change. The resident later reported not being asked about the move and not knowing when it occurred, while the charge LPN, DON, corporate nurse, and administrator all acknowledged that neither the resident nor the family had been notified in advance and that no documentation of such notification existed.
Two cognitively intact residents sharing a room experienced a persistently sticky floor, with one having hemiplegia/hemiparesis post-stroke and using a wheelchair, and the other having chronic right heart failure, HTN, and urinary incontinence. Over multiple observations, surveyors found the room’s floor sticky despite reports that it was mopped daily. One resident reported that a family member had to bring in a Swiffer to mop the floor due to the stickiness, and the other stated staff did not mop every day and seemed not to change mop water. Housekeepers and a CMT acknowledged that urine frequently leaked onto the floor from an incontinent resident and that the floor was sticky almost every day, yet some had not informed supervisors. An RN was aware of the sticky floor, while the DON and Administrator were either unaware of the ongoing condition or had not observed it, amid recent turnover and disruption in housekeeping leadership and staffing. This resulted in a failure to maintain a consistently clean and comfortable environment in the room.
Staff failed to follow wound care orders and obtain ordered Medihoney for a resident with a right BKA and a left ankle pressure ulcer. The resident was admitted with multiple lower-extremity wounds, and an outside practitioner later ordered daily cleansing and dressing changes using Medihoney for a suspected surgical site infection. Facility records showed days when wound care was placed on hold, not completed, or documented as provided without noting that Medihoney was unavailable, while staff substituted triple antibiotic ointment and, on two occasions, Medihoney brought from home by an RN without documentation or a physician order change. The supply record showed Medihoney on backorder, but there was no documented notification to the physician or DON about the lack of the ordered product, and interviews confirmed that leadership was not informed and that staff understood they should not bring medications from home or chart treatments as completed with supplies that were not used.
The facility failed to maintain an effective pest control system and to respond appropriately to an ant infestation in a resident room. A resident with dementia, adult failure to thrive, and extensive ADL assistance needs repeatedly reported ants in the room over several weeks. Staff documentation minimized the concern, suggesting hallucinations, despite the resident’s ongoing complaints. Surveyors later observed live ants on the floor of the room, which was near an exit door where ants had recently been seen. Housekeeping staff acknowledged seeing ants and receiving complaints but did not report the issue through the maintenance log. The DON reported personally seeing ants and verbally notifying maintenance, while the maintenance director denied knowledge of ants in resident rooms, relied on undocumented verbal reports, and had only minimal use of a newly created maintenance log. Pest control invoices showed general monthly services but no documented, targeted treatment for ants in the affected room, and the facility could not provide a pest control policy.
The facility failed to follow its own policy requiring prompt notification of a resident’s representative and physician after significant condition changes, including falls with injuries. A resident with Parkinson’s disease, mobility limitations, and a known fall risk experienced multiple unwitnessed falls resulting in a skin tear and a forehead hematoma. Nursing notes and fall tracking tools documented these events but did not show that the resident’s representative was notified. Staff interviews confirmed that family notification was either omitted or deferred between shifts, and leadership stated they expected all falls and notifications to be documented, which did not occur.
A resident with multiple chronic conditions and a known fall risk experienced an unwitnessed fall while transferring from bed to wheelchair and complained of bilateral hip pain. An RN assessed the resident, notified the physician, and obtained an order for bilateral hip x‑rays, which was entered into the system. However, subsequent nursing notes only documented routine fall follow‑up and normal neuro checks, with no documentation that the x‑ray was completed or that results were received. The resident later reported that no x‑ray had been done, the radiology company stated they had no record of any call or order from the facility, and the DON confirmed that the company had not received an order, demonstrating that the physician’s x‑ray order was not carried out or appropriately followed up.
The facility failed to timely report an allegation of verbal abuse to the state agency as required by its abuse policy. A resident with major depressive disorder, chronic pain, and CHF, and with intact cognition, told the SSD that a CNA was hateful, verbally abusive, refused to warm food, and refused to assist with repositioning. The SSD documented the allegation as verbal abuse on a grievance form, informed the Administrator that the CNA was rude, disrespectful, and mean, and told the DON he had witnessed disrespectful behavior. Although staff, including CNAs, the DON, and the Administrator, acknowledged that abuse allegations must be reported immediately to a supervisor and to the state within two hours, the DON stated she did not realize the grievance contained an abuse allegation, and the Administrator stated she was unaware of the allegation and did not check her email. As a result, the allegation was not reported to the state within the required timeframe.
A resident with intact cognition and diagnoses including major depressive disorder, chronic pain, and CHF reported that a CNA was hateful, verbally abusive, refused to warm food, and refused to assist with repositioning. The facility’s abuse policy required immediate reporting to the Administrator, a thorough investigation, and suspension of the alleged staff member from resident contact during the investigation, but the grievance was not effectively communicated to the Administrator, the DON did not recognize or act on the documented abuse allegation, and no written investigation or protective measures were documented. The CNA continued working with the resident and other residents while staff later described the conduct as borderline abuse, and the ADON reported not being informed of the allegation or involved in any investigation.
The facility did not consistently provide or document restorative nursing services as ordered and care planned for multiple residents with conditions such as muscle wasting, weakness, and mobility deficits. Despite having policies and physician orders for individualized restorative programs, services were often missed or undocumented due to staff being reassigned to other duties and lack of training on electronic documentation. Interviews and record reviews confirmed that residents did not receive the prescribed frequency of restorative interventions.
Staff failed to immediately report an allegation of employee-to-resident abuse involving a resident with dementia and moderate cognitive impairment. Although several staff members became aware of the allegation, there was a delay in notifying the Administrator and in reporting the incident to the state agency within the required two-hour timeframe, resulting in noncompliance with reporting policies.
A resident with diabetes did not receive prescribed insulin for several days after admission because staff failed to transcribe hospital discharge orders onto the facility's MAR. Blood glucose checks were performed, but insulin was not administered until the omission was discovered and new orders were obtained. Staff interviews confirmed that required procedures for medication transcription and review were not followed.
A staff member posted a photo on personal social media that showed a resident's face and another resident's medical information, violating facility policy on privacy and confidentiality. Multiple staff recognized the breach but did not immediately report it, and the incident involved residents with significant cognitive and medical conditions.
A resident with paraplegia and neuromuscular bladder dysfunction performed self-catheterization without a documented physician order specifying catheter size, frequency, or monitoring, and staff did not consistently document or monitor the procedure as required by facility policy. Interviews with nursing staff and leadership revealed uncertainty about the need for orders and monitoring, and the necessary documentation was not present in the resident's records.
A resident with cognitive impairment and swallowing difficulties was not provided with thickened liquids as ordered by the physician. Staff, including CNAs and nursing personnel, were unaware or did not verify the resident's dietary requirements, resulting in the resident receiving regular chocolate milk and water instead of nectar thick liquids. The dietary manager confirmed that nursing staff were responsible for preparing thickened drinks, but observations and interviews showed this was not consistently done.
A resident admitted with a stage 4 pressure ulcer and requiring a wound VAC did not have complete documentation of wound assessments, physician orders for the wound VAC, or records of wound care treatments. Staff performed dressing changes and managed issues with the wound VAC, but these actions were not consistently documented in the medical record, and required assessments were not completed as per facility policy.
A CNA physically and verbally abused a resident with moderate cognitive impairment during incontinence care by using excessive force and profane language after the resident refused care and became combative. Another CNA witnessed the incident and attempted to intervene. The event was reported, but required documentation in the electronic medical record was not completed as per facility policy.
Staff failed to obtain, enter, and document wound care orders and did not update care plans for three residents with wounds, including surgical incisions and skin tears. Wound care provided was not consistently recorded in the physician order sheet or treatment administration record, and care plans did not reflect current wounds or treatments. Interviews confirmed inconsistent practices and the absence of a facility policy for managing wound care orders.
A resident with significant physical and cognitive impairments alleged that a CNA roughly handled them during a transfer, resulting in discomfort and concern. The allegation was reported to an RN, who failed to notify management or the state agency as required by policy, instead conducting their own investigation and concluding it was not reportable. The incident was not reported to the state agency until the following day, exceeding the mandated reporting timeframe.
A resident with significant physical and cognitive impairments alleged physical abuse by a CNA, but the facility did not conduct a timely or thorough investigation. The initial response did not include immediate reporting to leadership, removal of the alleged perpetrator, or interviews with other staff and residents, contrary to facility policy.
A deficiency was identified due to the failure to provide safe and appropriate pain management for a resident in need. The facility did not adequately address the resident's pain management needs, indicating a lapse in ensuring the resident's comfort and well-being.
A deficiency was identified due to the failure to provide pharmaceutical services to meet the needs of each resident and the lack of a licensed pharmacist's services. This issue was noted during a survey event, indicating a lapse in ensuring proper pharmaceutical care.
A deficiency was identified concerning significant medication errors affecting residents. The event, noted during a survey, indicates that residents were not free from these errors, which is crucial for their care. Specific details about the actions or inactions leading to the errors are not provided.
A resident with severe cognitive impairment and multiple diagnoses was inappropriately moved by a CNA who pulled the resident by their feet across the floor. The incident occurred when the resident voluntarily lowered themselves to the floor, and the CNA, unable to lift the resident due to a narrow passage, chose to pull them into the day room. Staff interviews confirmed that this action was disrespectful and not in line with the facility's policy on resident dignity.
An LPN at the facility continued to work without a valid nursing license after their New Mexico-issued license was placed on probationary status. The facility's policy required verification of licenses, but the lapse in monitoring allowed the LPN to work without a valid license, potentially affecting resident care.
A long-term care facility failed to protect residents from medication misappropriation, as discrepancies in controlled medication counts were found for four residents. An LPN, appearing impaired, signed out medications at incorrect times without proper orders, leading to missing doses. The facility lacked regular audits and proper documentation, contributing to the issue.
The facility failed to provide adequate pain management for three residents due to unavailability of prescribed medications like acetaminophen, Lidocaine patches, and hydrocodone. Residents experienced increased pain, and staff did not contact physicians about the shortages. Systemic issues with medication ordering and access, especially for agency staff, were identified.
The facility failed to consistently document and reconcile controlled substances due to inadequate practices by staff. The October 2024 logs showed multiple instances of missing initials and undocumented medication packages across four medication carts. Interviews revealed that staff were unaware of these lapses, and there was no regular audit process to ensure compliance, leading to ongoing deficiencies in pharmaceutical services.
The facility failed to prevent significant medication errors when residents with diabetes did not receive insulin due to a lack of glucometer test strips for blood sugar checks. A resident with cognitive impairment missed several insulin doses, and staff did not notify the physician or seek guidance. Another resident missed a Lantus dose, but the physician was informed, and no symptoms were observed. The issue was known among staff, but poor communication and management of supply orders contributed to the deficiency.
A resident who returned from the hospital after a toe amputation did not receive timely administration of the prescribed antibiotic, linezolid, due to unavailability and insurance authorization issues, resulting in a 33-hour delay. Additionally, the facility failed to monitor and document the condition of the resident's wound dressing, which was observed to be saturated with drainage. The lack of documentation and communication among staff members contributed to the deficiency in care.
A resident with a history of dementia and diabetes was readmitted to the facility with pressure ulcers on the buttocks. The facility failed to document complete wound assessments or obtain timely physician orders for treatment. Staff attempted to remove a hospital-applied dressing, resulting in further skin damage. Lack of communication and coordination among staff contributed to inadequate wound care.
A deficiency was identified where a resident, their doctor, and a family member were not immediately informed of situations affecting the resident, such as injury or decline. This was documented under event ID 7LS712.
A deficiency was identified where the facility failed to provide appropriate treatment and care according to the orders, preferences, and goals of the residents. This issue was documented under specific identifiers and noted by surveyors during an event.
A deficiency was identified in the facility's handling and securing of resident-identifiable information and medical records, failing to meet accepted professional standards.
A resident with Parkinson's and dementia reported being treated disrespectfully by a CNA, who was witnessed by multiple staff members speaking in a rude and loud manner. Despite reports to a nurse, no action was taken, and administrative staff were unaware of the behavior. The facility's policy lacked specific guidance on treating residents with dignity.
A resident with severe cognitive impairment fell and sustained injuries, but the LTC facility staff failed to notify the physician and family promptly. Despite the facility's policy requiring immediate notification, the incident was not communicated until much later, as revealed through staff interviews and documentation review.
The facility failed to conduct timely neurological checks after a resident's fall with a head injury and did not ensure all nursing staff were aware of the incident, leading to delayed response to x-ray results showing a fracture. Additionally, the facility did not complete an ordered urinalysis timely and failed to administer medications for a UTI as ordered for another resident, resulting in inadequate care.
A resident with severe cognitive impairment and a history of falls experienced a fall resulting in injuries, including a fracture. Despite x-ray orders and findings, the facility staff failed to document the x-ray results or actions taken, leading to incomplete medical records. Interviews confirmed that the charge nurse is responsible for documentation, but lapses occurred across shifts.
Failure to Follow Approved Menus and Portion Sizes Resulting in Inadequate Meal Portions
Penalty
Summary
Facility staff failed to ensure that meals were served according to the approved menus and portion sizes, resulting in residents receiving smaller portions than specified. The facility’s policies required use of standardized recipes and diet spreadsheets or similar tools, with serving portions based on the planned menu and approved by the registered dietician. On a dated menu specifying three chicken tenders, macaroni and cheese, mixed vegetables, and chilled peaches, observation showed a dietary staff member placing only two chicken strips on each resident’s plate. For pureed diets, the menu called for 2/3 cup pureed chicken tenders, 1/2 cup macaroni and cheese, and 2/5 cup mixed vegetables, but observation showed the same staff member serving only 1/2 cup pureed chicken tenders, 1/2 cup macaroni and cheese, and 1/4 cup mixed vegetables to residents receiving pureed meals. Two cognitively intact residents reported that they routinely did not receive enough food. One resident, with diagnoses including hemiplegia, type II diabetes, and major depressive disorder, stated that they received small portions almost every meal and that on one evening the only food provided was a chicken pot pie. Another resident, with diagnoses including pre-diabetes, depression, and diverticulitis, reported not getting enough food, describing a meal where they received a hotdog and only one teaspoon of sauerkraut, and stating that the food served on the survey day was more than they normally received. Both residents had care plans indicating that their dietary preferences were to be honored, with specific favorite foods identified. Multiple dietary and nursing staff interviews confirmed that menu portions and scoop sizes were not consistently followed and that residents frequently received less food than called for on the menus. One dietary staff member stated that menus posted by the Dietary Manager (DM) listed required quantities and that they saw the menu called for three chicken strips but were told by the DM to serve two. Another dietary staff member reported they did not really know how much food to cook and “eyeballed” amounts, and that when there was not enough food, the DM instructed staff to serve smaller portions; this staff member reported using smaller scoops for pudding and serving half the casserole portion specified on the menu. CNAs, an LPN, and a CMT reported that residents consistently received small portions, that one unit received about half the amount of food compared to the rest of the facility, that residents on pureed diets often did not get enough food, and that some meals consisted only of soup and bread or a sandwich and chips. The DM and RD both stated that staff were expected to serve the amounts specified on the menus, and the RD reported being told by various residents that they were not receiving enough food.
Failure to Honor Resident Shower Preferences and Provide Consistent Bathing Opportunities
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ reasonable shower preferences and to support resident choice and self-determination regarding bathing. The facility had no policy on showers and multiple residents reported inconsistent or significantly delayed showers despite care plans and MDS assessments indicating that bathing choices were very important to them. Documentation in shower sheets and progress notes frequently showed long gaps between showers without any recorded refusals, while staff interviews confirmed that showers were not consistently provided, often due to staffing issues and unclear processes for scheduling and documentation. One cognitively intact resident with hemiplegia, heart disease, COPD, diabetes, depression, incontinence, and significant ADL deficits was documented as receiving showers at intervals of 5–7 days in February, then going 14 days between showers in March, with a subsequent 9‑day gap and no refusals documented. This resident stated that the last few scheduled showers were missed due to short staffing, believed they smelled, felt others would not want to be around them, and expressed a desire for two showers per week. Another cognitively intact resident with lumbar spondylosis with myelopathy, osteoarthritis, osteoporosis, muscle wasting, and mobility limitations had documented shower intervals of 11 days in February and 18 days in March, with no additional showers or refusals recorded. This resident reported sometimes going two weeks or longer without a shower, described inconsistent shower provision related to changing staff, recounted an instance where a staff member said they did not want to get wet so the resident had to shower without assistance, and reported feeling dirty, embarrassed, itchy, and having oily, greasy hair. A third cognitively intact resident with hemiplegia/hemiparesis after stroke, COPD, depression, bowel incontinence, and total dependence on staff for most ADLs had documented showers on two dates in early February, then no further showers until early March, resulting in a 25‑day gap without any documented refusals, followed by 7‑ and 14‑day gaps between subsequent showers. The resident stated they were supposed to receive two showers per week but were lucky to get one every two weeks, reported that staff had promised a shower on a specific day that did not occur, denied refusing showers, and said they felt neglected when showers were not provided as expected. A fourth resident with dementia, osteoarthritis, spinal stenosis, incontinence, and ADL deficits had showers documented twice in February, then not again until mid‑March, creating a 26‑day gap with no refusals documented. This resident reported usually getting only one shower per week and only if enough staff were available, recalled previously receiving two showers per week, and expressed concern about smelling bad and using extra deodorant when showers were missed. Staff interviews further described systemic issues with shower provision and documentation. Multiple CNAs and CMTs stated that residents were supposed to be offered showers twice weekly, but acknowledged problems with residents actually receiving showers, citing short staffing, unclear division of responsibility among aides, and confusion about whether showers were documented on paper sheets or in the electronic medical record. One CNA reported hearing complaints from various residents that they had gone two weeks without a shower and believed residents were not getting showers consistently. The DON acknowledged that showers had been a problem in the past, described a room‑based shower schedule intended to provide two shower days per week, and stated that they should be reviewing shower sheets but had not done so. The administrator and DON both indicated that if the electronic record showed “not applicable,” the resident did not receive a shower, and staff confirmed that if there was no documentation, no shower had occurred. These actions and inactions resulted in multiple residents not receiving showers in accordance with their expressed preferences and the facility’s stated expectation of two showers per week.
Resident Rights Violated When Nurse Forces Wheelchair Transfer Against Resident’s Wishes
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to dignity, self-determination, and to be treated with respect when a nurse insisted on placing the resident into a wheelchair against the resident’s expressed wishes. The resident involved had diagnoses including Alzheimer’s disease, anxiety, depression, low back pain, cognitive communication deficit, and unspecified dementia with agitation. The admission MDS documented memory problems, no behaviors, and impairment on one side. The resident’s care plan specifically identified a behavior of lowering self to the floor and scooting around, and directed staff that when the resident became restless, they should assist the resident to the floor to scoot, noting that the resident did not think it was wrong to scoot on the floor. On the day of the incident, the resident was on the floor in or near the nurses’ station, consistent with the care plan. According to a progress note by an LPN and written and verbal statements from CNAs, the resident had scooted into the office/nurses’ station area. CNA staff were attempting to guide the resident out and had obtained the resident’s wheelchair to have it available if the resident chose to use it. Multiple staff accounts state that when the resident was asked if they wanted to get up into the wheelchair, the resident said no and did not want to get up. Despite this, RN F, who did not regularly work on that unit and did not know the resident, told staff that they did not care what the resident wanted and directed that the resident be placed into the wheelchair. Staff reports and RN F’s own interview indicate that RN F placed an arm under the resident’s arm and, with assistance from a CNA, lifted the resident into the wheelchair without obtaining the resident’s consent and without recalling that anyone asked the resident if they wanted to transfer. The resident resisted during the transfer and, once placed in the wheelchair, struck RN F. Multiple CNAs, a CMT, the DON, and the Administrator all stated that the resident was care planned to scoot on the floor and that it would be against the resident’s rights to force a transfer to a wheelchair if the resident did not want to get up. RN F later acknowledged that it was against the resident’s rights to force them up and that the resident had the right to remain on the floor. This sequence of events demonstrates that the resident’s care-planned behavior and expressed wishes were disregarded, resulting in a violation of the resident’s right to dignity and self-determination.
Failure to Follow Through on Custom Wheelchair Order and Accommodate Resident Mobility Needs
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s need for a customized wheelchair despite an active physician order and documented discomfort with the current wheelchair. The resident had a history of hemiplegia and hemiparesis following a stroke, muscle wasting, COPD, chronic pain, and dependence on staff for transfers and most ADLs. The care plan identified hemiplegia/hemiparesis, pain management needs, dependence for mobility and repositioning, and the use of a wheelchair, with an order dated 01/22/26 for a custom wheelchair for proper positioning related to right hemiplegia and hemiparesis. Nursing documentation noted the resident reported back pain from lying on his/her back most of the time and that using the wheelchair at times helped relieve some pain. During interview, the resident stated the current wheelchair was uncomfortable, that he/she could only tolerate sitting in it for about 20 minutes before needing to return to bed due to pain, and that staff had largely stopped asking him/her to go to the dining room after multiple refusals. The facility’s own Durable Medical Equipment policy outlined detailed requirements and processes for obtaining custom wheelchairs, including physician face-to-face examinations, therapy evaluations, ATP involvement, prior authorization, and documentation standards. However, staff interviews revealed confusion and lack of clarity about the internal process for ordering and following through on a custom wheelchair, particularly for residents not currently on therapy. The physical therapy director reported that a custom wheelchair request originated around June 2025 during a care plan meeting, that he/she completed at least one evaluation and a wheelchair form, and placed the form in a physician’s folder for signature. He/she stated that for several weeks he/she moved the form to the front of the physician’s folder, later found the papers missing, and assumed the form had moved forward in the process. When a nurse practitioner later asked for the form and reported not having seen it, the therapy director completed another form and again placed it in the same physician’s folder. The therapy director stated he/she does not usually receive signed forms back and did not know whose responsibility it was to complete the process after the physician signed. Multiple staff members, including the DON, social services director, business office manager, and administrator, gave inconsistent or incomplete descriptions of who was responsible for ordering and tracking the custom wheelchair. The DON stated he/she did not know the facility’s process for assisting residents with obtaining a customized wheelchair, believed therapy “headed that up,” and thought social services might be involved but was unsure. The social services director, who had been in the role for three weeks, reported not knowing the process for ordering a custom wheelchair, not being aware of any medical equipment ordering policy, and deferring questions to the administrator or business office manager. The business office manager stated that wheelchair orders go through therapy and that he/she had no paperwork regarding the custom wheelchair order dated 01/22/26. The administrator stated that the DON should be following and reviewing physician orders to ensure they are carried out, acknowledged there was an active order for a custom wheelchair in the chart, and was unsure if anyone was working on obtaining it or what had happened after therapy contacted the equipment company. The medical director confirmed signing an order for a custom wheelchair in January 2026 and said he/she expected the wheelchair to be in place by now, but there was no documentation in the record of his/her follow-up call to a wheelchair company. Overall, there was no documentation in the resident’s record or in facility files showing that the custom wheelchair order had been processed, tracked, or completed, resulting in the resident continuing to use an uncomfortable standard wheelchair and remaining largely bedbound despite an order and policy framework intended to support provision of a custom wheelchair. Additional interviews further illustrated the lack of follow-through and coordination. The physical therapy director reported that the resident had at times expressed liking the existing wheelchair to him/her while telling family it was uncomfortable, that the resident had refused trying a larger facility wheelchair offered as a trial, and that the resident had long periods of remaining in bed, including about eight months when he/she did not get out of bed. The therapy director also stated that he/she recalled telling the family they would need to pick a wheelchair company but never heard back, and that he/she had no paperwork in the therapy file related to the custom wheelchair process. Nursing staff, including an RN and an LPN, reported not being aware of the resident requesting or needing a new wheelchair and noted that the resident rarely got out of bed, typically only for showers, with transfers requiring a Hoyer lift and two staff. The DON stated that therapy had indicated they could not get the resident out of bed and therefore saw no need for a new wheelchair, and also stated that the resident did not qualify to have the wheelchair paid for, while acknowledging that he/she would expect the January 22 order to be resolved or at least have documented progress. Collectively, these actions and inactions show that despite an identified need, an active physician order, and a facility policy describing the process for obtaining custom wheelchairs, the facility did not ensure that the resident’s custom wheelchair was ordered, tracked, and obtained, and did not reasonably accommodate the resident’s need for appropriate seating and mobility. Staff interviews also showed that the facility lacked a clear, consistently understood process for ordering and tracking custom wheelchairs. The physical therapy director described a general sequence of identifying need, performing a wheelchair evaluation, contacting a medical supply company, completing forms, and placing them in a physician’s folder, but could not identify who was responsible for subsequent steps after physician signature. The DON believed therapy initiated the process and that the family would select the DME company, while the administrator stated that the social worker had no role and that equipment would be ordered by maintenance, the DON, and/or the administrator. The social services director believed maintenance ordered beds and similar equipment and that any resident equipment needs would be cleared through the administrator. No one could produce a policy specific to physician orders or a documented workflow for custom wheelchair procurement. This lack of defined responsibility and documentation resulted in the resident’s custom wheelchair order remaining unresolved for an extended period, despite the resident’s ongoing discomfort and limited tolerance for the existing wheelchair.
Failure to Notify Resident and Representative Prior to Room Change
Penalty
Summary
Facility staff failed to provide required notice to a resident or the resident’s representative prior to a room change. The resident, admitted on 05/16/25, had diagnoses including atherosclerotic heart disease, hypertension, dementia, anxiety, and age-related cognitive decline, and had severe cognitive impairment and used a wheelchair per the 03/20/26 MDS. The care plan dated 05/19/25 indicated the resident preferred family involvement in care discussions. Census records showed multiple prior room moves in 2025, and on 03/25/26 surveyors observed the resident’s former room on the special care unit was empty and the resident’s name had been placed on a different room. Review of the medical record, including nurses’ notes, revealed no documentation of a room change on that date and no documentation that the room change had been discussed with the resident or the resident’s representative. Interviews confirmed that the resident was moved that afternoon to make the original room available as a private room for a new private-pay admission. A CNA reported the resident was moved around 2:00 p.m., that the resident generally got along with others, and that it was unclear whether the resident understood the move. The resident stated staff did not ask if he or she wanted to be moved, did not know when the move occurred, but was accepting of the new room and roommate. The charge LPN on the special care unit stated housekeeping moved the resident, that he or she only received a written note from Maintenance after the move, believed the family should have been notified but was not, and acknowledged there was no documentation of notification. The DON, corporate nurse, and administrator all confirmed the resident was moved to accommodate a new admission needing a private room, that the resident and family were not notified before the move, and that there was no documentation or paperwork showing prior notification of the room change.
Persistent Sticky Floor and Inadequate Cleaning in Shared Resident Room
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe, clean, comfortable, and homelike environment when staff failed to ensure that the floor in a shared resident room was properly and frequently cleaned, resulting in a persistently sticky floor for two residents. One resident had hemiplegia and hemiparesis following a stroke affecting the left side, used a wheelchair, was cognitively intact, and was dependent on staff for activities, cognitive stimulation, and social interaction. This resident reported that a family member had recently brought in a wet Swiffer sweeper and mopped the floor twice because it was sticky. Another cognitively intact resident in the same room had chronic right heart failure, high blood pressure, and a communication problem, and reported that staff did not mop the room every day and that the floor stayed sticky due to urinary incontinence. On multiple observations over two days, surveyors found that the floor in the room shared by the two residents was sticky each time it was checked. One resident stated that staff did mop the floor but believed they did not change the mop bucket water, which he thought contributed to the floor remaining sticky. Housekeeping staff interviews revealed awareness that the floor in this room was sticky almost every day and that one resident was incontinent of urine, with urine frequently seen on the floor and coming out of the resident’s incontinence brief. Housekeepers reported using the same disinfectant mopping process in this room as in other rooms, changing mop water by hall, and some stated they planned to tell or had not told their supervisor about the persistent stickiness. Nursing and administrative staff interviews further showed that several staff members, including a CMT and an RN, were aware that the floor in the room was sticky almost every day, but they had not reported this to supervisors. The DON stated not having noticed the sticky floor but acknowledged that the room was usually a mess and that staff had tried using special cleaning wipes and mopping. The DON also reported recent turnover in housekeeping leadership, with the prior head housekeeper leaving and new housekeeping staff and a new housekeeping supervisor just starting, and that nursing staff were helping with laundry. The Administrator stated not knowing that the floor was sticky and was unsure what nurse aides would use to clean urine from the floor when housekeeping was not present. These observations and interviews demonstrated that the facility did not ensure effective cleaning practices or communication to address the ongoing sticky floor condition in the residents’ room.
Failure to Follow Wound Care Orders and Obtain Ordered Medihoney for Amputation and Pressure Ulcer
Penalty
Summary
Facility staff failed to provide wound care per physician orders and standards of practice for one resident with a right below-knee amputation (BKA) and a left ankle pressure ulcer. The resident was admitted with a history of type 2 diabetes mellitus, cellulitis of the right lower limb, a left ankle pressure ulcer, a right foot amputation, and a non-pressure chronic ulcer of the right ankle. On admission, staff did not document wound measurements for the surgical site because they reported they could not remove the outer dressing until the next orthopedic appointment, and the right BKA site was not evaluated on the following day. The care plan directed staff to administer treatments as ordered, monitor dressings, consult wound care as appropriate, and provide wound care per treatment orders, but the facility did not have a wound care treatment and management policy and did not provide a policy regarding physician’s orders. On a follow-up visit, an outside practitioner diagnosed a suspected surgical site infection at the BKA stump and ordered daily local wound care with TheraHoney along the incision line, with daily dressing changes and cleansing. The corresponding physician order and TAR entry specified daily wound care using TheraHoney. However, documentation showed multiple days where wound care was placed “on hold,” not completed, or recorded as refused without detailed progress notes. Staff documented that TheraHoney was not available and substituted triple antibiotic ointment on at least two dates, while on many other dates they documented that wound care was provided without noting that the ordered TheraHoney was unavailable. The facility’s supply order for TheraHoney was placed mid-month and showed the product as backordered with an estimated ship date more than a month later, yet there was no documentation that the physician or pharmacy was notified about the unavailability of TheraHoney during this period. Interviews revealed that nursing staff knew the ordered Medihoney/TheraHoney was not available but did not consistently notify the physician or DON, and did not consistently document calls to the pharmacy or supply company. One RN stated the pharmacy never sent the Medihoney, acknowledged failing to document calls to the pharmacy, and admitted bringing Medihoney from home, transferring it into a cup, and using it twice on the resident’s wound without documentation and without other staff access. Staff also reported using triple antibiotic ointment in place of Medihoney without evidence of a corresponding physician order change, and the DON stated he did not know what was being used in place of Medihoney and that no staff had informed him it was unavailable. The resident reported that staff had used triple antibiotic ointment instead of the ordered Medihoney, that wound dressings had been changed only a few times over a multi-week period, and that the surgeon was upset that Medihoney had not been available for dressing changes. A later follow-up visit documented necrotic tissue on the BKA stump and resulted in new orders for wet-to-dry dressings and dry dressings with optional Medihoney if available, but facility records still lacked documentation of timely notification to the physician about the earlier lack of Medihoney and the substitutions that had been made. The facility’s own skin policy addressed weekly skin checks, documentation of wound appearance and measurements, and staging of pressure injuries, but there was no wound care treatment and management policy provided, and no policy regarding physician’s orders. Interviews with the DON, administrator, LPN, and medical director consistently indicated that staff were expected to follow wound care orders as written, notify the physician and leadership when supplies were unavailable, avoid bringing medications from home, and accurately document when treatments were not completed or when substitutions were made. Despite these stated expectations, the record showed repeated undocumented deviations from the physician’s wound care orders, undocumented missed or delayed dressing changes, use of non-ordered products, and lack of timely communication with the physician about the unavailability of ordered wound care supplies for this resident’s BKA stump and left ankle wound.
Failure to Maintain Effective Pest Control and Respond to Ant Infestation in a Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control system when live ants were present in one resident’s room and there was no clear pest control policy available. Review of pest control invoices over several months showed routine, general pest control services for rodents and occasional invaders, including interior perimeter treatments and rodent trap maintenance, as well as a chemical treatment of a specific room for potential bed bugs. However, these records did not document targeted treatment for ants in the affected resident room, and the facility could not provide a pest control policy. The administrator was unsure of the exact timing and scope of pest control services, including whether resident rooms were sprayed. The resident involved had multiple chronic conditions, including osteoarthritis, muscle wasting, dementia, spinal stenosis, adult failure to thrive, and required extensive assistance with activities of daily living, including toileting, bathing, dressing, and personal hygiene. A progress note documented that the resident reported having a lot of ants in the room, but the writer of the note did not see ants and suggested the resident might be hallucinating or misperceiving due to poor vision. The note also stated that facility staff did not know of any ant issue at that time. Despite this, the resident later reported that ants had been present in the room for a few weeks and stated that housekeeping staff had seen the ants. On observation of the resident’s room, surveyors saw live ants crawling on various areas of the floor, with only one sealed package of crackers present on the bedside table and no ants around the food. The room was located next to the 100 hall exit door, where the maintenance director acknowledged having addressed an ant problem a few days earlier using hot water, without documenting this or initiating further pest control measures. The maintenance director stated he had not been informed of ants in the resident’s room and that staff were not consistently using the maintenance log to report issues. Housekeeping staff admitted seeing ants in the resident’s room and receiving complaints from the resident but had not reported the issue in the maintenance log or directly to maintenance. The DON reported personally seeing ants in the resident’s room and stated that the concern had been verbally relayed to maintenance approximately one to two weeks earlier, but there was no documentation of follow-up or room-specific pest treatment, and the maintenance director continued to deny knowledge of ants in resident rooms. These actions and inactions resulted in ongoing ant activity in the resident’s room without timely, documented, and effective pest control intervention. The facility’s internal communication and documentation systems for maintenance and pest issues were inadequate. The maintenance director reported that when he started, there were no inspection forms or maintenance records, and he had only recently created a maintenance request folder at the nurse’s station, which contained just one unrelated entry. He stated that he looked in every resident room weekly but did not document these inspections or specify what he checked. Staff frequently reported issues to him verbally instead of using the log, and he acknowledged difficulty remembering all verbal reports. The DON stated that she had never seen the pest control company spray at the facility and that maintenance had told her he could not spray for ants, indicating uncertainty about how pest control services were being implemented in resident care areas. Together, these factors contributed to the failure to identify, document, communicate, and effectively address the ant infestation in the resident’s room.
Failure to Notify Resident Representative of Multiple Falls and Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of multiple falls and related injuries in a timely manner, contrary to its own policy on significant condition changes and notification. The facility’s policy, dated 12/24, required licensed nurses to notify the resident’s family/representative and medical practitioner of changes such as new wounds, bruises, skin tears, head trauma, and mobility changes, and to document each attempt at notification. Despite this, documentation for one resident showed repeated falls and injuries without corresponding evidence that the resident’s representative was informed. The resident involved was admitted on 09/09/24 with diagnoses including Parkinson’s disease, cognitive communication deficits, and a history of falling. An admission MDS dated 12/04/25 indicated the resident was cognitively intact, able to walk with a walker, and required maximum assistance for toileting. The care plan updated 01/28/26 identified limited physical mobility due to weakness, risk for falls related to disease process and muscle weakness, use of a wheelchair, and unwitnessed falls on 02/11/26, 02/19/26, and 02/21/26. Nursing progress notes and fall risk data collection tools documented unwitnessed falls on 02/11/26, 02/14/26, 02/19/26, and 02/21/26, including a skin tear to the right forearm and a hematoma to the right side of the forehead, but did not include documentation of responsible party notification for any of these events. Interviews with nursing staff and leadership confirmed that family notification did not occur as required. One LPN stated that for unwitnessed falls, staff start neurological checks and notify the doctor and family, but also indicated that non-injury night-shift falls could be reported on day shift. Another RN reported that the night-shift nurse had not notified the family of a fall and that the RN also did not notify the family; the resident’s family member later discovered bruising to the resident’s head and requested hospital evaluation. Additional LPNs acknowledged monitoring the resident after falls and starting neurological checks but either did not notify the family or deferred notification to the next shift. The DON and Administrator both stated they expected staff to notify the physician and family for all falls and to document both the fall and notifications, which did not occur in this case.
Failure to Ensure Ordered Post‑Fall X‑Ray Was Completed and Tracked
Penalty
Summary
Staff failed to follow physician orders and facility policy for diagnostic testing after a resident’s fall, resulting in ordered bilateral hip x‑rays not being completed or tracked. The resident, who had multiple diagnoses including type 2 diabetes with hyperglycemia, chronic right heart failure, chronic respiratory failure with hypoxia, muscle wasting, right knee pain, and lymphedema, was care planned as at risk for falls and required moderate assistance with transfers. The care plan noted prior witnessed and unwitnessed falls and interventions such as education on using the call light and ensuring the wheelchair was locked. On the evening of 02/16/26, RN A documented that the resident was found on the floor on the left hip beside the bed after an unwitnessed fall while attempting to transfer from bed to wheelchair. A head‑to‑toe and skin assessment were completed, and the resident complained of bilateral hip pain. The resident’s family, physician, and management were notified, and a new order was received for bilateral hip x‑rays. The physician order sheet reflected an order dated 02/17/26 for bilateral hip x‑rays due to the fall and increased hip pain. Subsequent progress notes on 02/17/26, 02/18/26, and 02/19/26 documented ongoing fall follow‑up, normal vital signs and neuro checks, and no complications or signs of pain, but did not document that the x‑ray was obtained or that results were received. Record review showed no x‑ray results in the resident’s chart, and the resident later reported having had a fall about a week earlier with leg pain and stated that no x‑ray had been done since. RN A reported placing the x‑ray orders in the computer, calling the radiology company, being told they would come the next day, preparing a packet for radiology, and then calling again when they did not arrive, but acknowledged not documenting these contacts and not knowing why the x‑ray was never done; the prepared packet remained at the facility. The radiology company reported having no record of any calls from the facility regarding this x‑ray order and stated they document every call received. The DON confirmed that the radiology company reported never receiving an order, that staff must call the company for x‑rays to be done, and that the physician’s orders for the x‑ray were not followed.
Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of possible verbal abuse to the state agency (DHSS) within the required two-hour timeframe, as required by its Abuse, Prevention and Prohibition Policy. The policy stated that any employee or agent made aware of an allegation of abuse or neglect must ensure it is reported to the mandated state agency and law enforcement no later than two hours after the allegation is made. On 12/31/25, the Social Service Director (SSD) documented on a grievance form that a resident reported a CNA was hateful and verbally abusive, became mad when the resident asked for things, and refused to assist the resident to get up. Despite this documentation and the facility’s policy, DHSS records showed the allegation was not reported. The resident involved had been admitted on 12/27/25 with diagnoses including major depressive disorder, other chronic pain, and congestive heart failure, and the admission MDS indicated intact cognitive skills. The resident’s care plan, revised 01/05/26, reflected mood and behavior problems, including refusal to get out of bed and refusal of therapy. On 12/31/25, the SSD spoke with the resident, who stated that every time the CNA came in, the CNA was mean, refused to warm up the resident’s food, and refused to pull the resident up in bed. The SSD documented the resident’s statement of verbal abuse on the grievance form and reported to the Administrator that the resident said the CNA was rude, disrespectful, and mean, and also informed the DON that he had witnessed the CNA being disrespectful and dismissive toward the resident. Multiple staff interviews confirmed that facility staff understood that any allegation of abuse must be reported immediately to a supervisor and to the state within two hours. CNA A and CNA B both stated that allegations of abuse should be reported to the charge nurse and to the state within two hours. The DON and Administrator each stated that staff should report allegations of abuse to them immediately and that the facility should report to the state within two hours. However, the DON stated she did not think she understood that the word “abuse” was on the grievance form, and the Administrator stated she did not know of the allegation of abuse on the grievance form until the survey date and had not checked her email. The SSD stated he emailed the grievance form to the Administrator and believed the resident had stated verbal abuse, but no one reported the allegation to DHSS within the required timeframe, resulting in the deficiency.
Failure to Investigate Verbal Abuse Allegation and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse in a timely manner and to implement protective measures for all residents during the investigation. The facility’s Abuse, Prevention and Prohibition Policy required immediate reporting of abuse allegations to the Administrator, a thorough investigation, and barring the alleged perpetrator from resident contact through suspension while the investigation was ongoing. A grievance form dated 12/31/25 documented that a resident reported CNA A was hateful, verbally abusive, refused to warm the resident’s food, and refused to assist the resident to get up. The resident’s admission MDS showed intact cognition, and diagnoses included major depressive disorder, other chronic pain, and CHF. The Social Service Director documented the grievance and reported informing the Administrator that the resident described CNA A as rude, disrespectful, and mean, including refusing to warm food and pull the resident up in bed, and stated the resident did report verbal abuse. The SSD then took the grievance form to the DON as instructed. The Administrator later stated she did not know about the abuse allegation on the grievance form until the survey date and did not recall being informed of what was written on the form. The DON acknowledged she was responsible for investigating abuse allegations but stated she did not think she understood that the word “abuse” was on the grievance form and was unsure if she saw “verbally abusive” on it. Despite the policy requiring immediate suspension of an employee alleged to have committed abuse, CNA A was not suspended and continued to work with the resident and other residents. CNA A reported that the DON had called him/her into the office the prior week and relayed that staff said CNA A threw down the resident’s meal tray, served cold food, told the resident “you get what you get,” did not assist the resident up in bed, and told the resident to butt out of the roommate’s care, which the DON described as borderline abuse. The ADON reported she was unaware of the allegation and stated that staff should notify the Administrator immediately and obtain statements from residents and staff during an abuse investigation. The facility was unable to provide a written investigation or documentation of steps taken to protect all residents during the investigation of this allegation.
Failure to Provide and Document Ordered Restorative Services
Penalty
Summary
The facility failed to provide restorative services as ordered and care planned for four residents, resulting in a deficiency related to maintaining or improving range of motion (ROM) and mobility. Despite having policies in place that required individualized restorative nursing programs, documentation, and regular evaluation, staff did not ensure that restorative services were consistently provided or properly documented. Observations, interviews, and record reviews revealed that residents with diagnoses such as chronic heart failure, COPD, muscle wasting, generalized weakness, and dependence on mobility aids did not consistently receive the restorative interventions outlined in their care plans and physician orders. For each resident, care plans and physician orders specified restorative programs such as use of NuStep equipment, ambulation with assistive devices, and strengthening exercises. However, documentation of these services was frequently missing or incomplete. Handwritten notes, rather than entries in the electronic medical record, were used by the restorative aide, who had not been trained on electronic documentation. Several residents reported infrequent or discontinued restorative sessions, and staff interviews confirmed that the restorative aide was often reassigned to work as a CNA on the floor, limiting the time available for restorative care. Interviews with staff, including the restorative aide, DON, and other nursing personnel, confirmed a lack of a systematic process to ensure restorative services were delivered as ordered. The restorative aide reported being pulled to floor duties frequently and not being able to consistently provide or document restorative care. The Director of Rehab and other staff acknowledged that recommendations for restorative therapy were made but not always followed through due to time management issues and lack of clear scheduling. As a result, residents did not receive the frequency or consistency of restorative services required to maintain or improve their functional abilities.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency within the required two-hour timeframe. An allegation of employee-to-resident abuse involving a resident with dementia and moderate cognitive impairment was not reported in a timely manner. The incident reportedly occurred late at night, but the facility administrator was not notified until several days later, and the state agency was not informed until hours after the administrator became aware. Documentation and interviews revealed that multiple staff members became aware of the resident's allegation that a staff member engaged in inappropriate behavior in the resident's room. The information was discussed among CNAs and reported to the nurse on duty, but there was a delay in escalating the report to the Director of Nursing and the Administrator. The Administrator only became aware of the allegation days after the incident, and the required report to the state agency was not made within the mandated two-hour window after the allegation was known to facility management. The resident involved had recently been admitted, had a diagnosis of dementia, and was dependent on others for activities of daily living. The facility's own policies required immediate reporting of abuse allegations to management and the state agency, but these procedures were not followed. Staff interviews confirmed knowledge of the reporting requirements, yet the delay in reporting resulted in noncompliance with state and facility policies.
Failure to Transcribe and Administer Insulin Orders on Admission
Penalty
Summary
Staff failed to ensure that a resident with type 2 diabetes mellitus received prescribed insulin upon admission. The resident was admitted with hospital discharge orders for both Humalog (fast-acting insulin) and insulin glargine (long-acting insulin), including specific sliding scale instructions for administration. However, these orders were not transcribed onto the facility's physician order sheet or medication administration record (MAR) at the time of admission. For six days following admission, the resident did not receive the prescribed insulin. Documentation shows that blood glucose checks were performed, but insulin was not administered as ordered until the issue was identified and new orders were obtained from the physician. Interviews with staff revealed that the admitting nurse was responsible for transcribing discharge medications, and the DON and ADON were expected to review these orders the day after admission. This review did not occur, and the omission was only discovered after the resident and staff raised concerns about missing insulin orders. The resident reported not receiving insulin since admission and expressed concern to staff. Multiple staff interviews confirmed that the process for transcribing and double-checking new admission medication orders was not followed, resulting in the resident missing critical diabetes medication for several days. The facility's policies required medications to be administered as prescribed and for errors to be analyzed and corrected, but these procedures were not adhered to in this instance.
Staff Social Media Post Breaches Resident Privacy and Confidentiality
Penalty
Summary
A staff member at the facility posted a photo to their personal social media account that included the visible face of one resident and private medical information of another resident. The photo, which was posted by an LPN, showed a resident sitting in the background and a neurological assessment document with another resident's full name, room number, and vital signs. Multiple staff members observed the post, which was accessible on the LPN's social media page, and recognized that it contained both identifiable resident imagery and confidential health information. The facility's policies explicitly prohibit the unauthorized disclosure of resident information, including names, photos, and medical records, on social media or any public platform. Staff interviews confirmed that it is against policy to post resident photos or medical information online, and that any such incidents should be reported to the Administrator. Despite this, the staff who initially saw the post did not immediately report it, and the incident only came to the Administrator's attention after being shown the post by another staff member. The residents involved had significant medical histories, including diagnoses such as cerebrovascular disease, Alzheimer's disease, heart failure, and dementia with anxiety. The posted documentation included sensitive health information, and the photo was taken and shared without the required consent for personal or public use. The facility's leadership, including the DON and ADON, confirmed that such actions were inappropriate and not in line with facility policy.
Failure to Obtain and Document Orders for Self-Catheterization
Penalty
Summary
The facility failed to ensure proper catheter use and care in accordance with standards of practice for a resident who performed self-catheterization. The facility's policies required a physician's order specifying the procedure, catheter size, frequency, and monitoring, as well as documentation of catheter care and any related observations or issues. However, record review revealed that there were no documented physician orders for the resident's self-catheterization, nor was there evidence of staff monitoring or documentation of the procedure in the resident's medical record or treatment administration record. The resident involved had a history of paraplegia, neuromuscular dysfunction of the bladder, and was dependent for transfers. Upon admission, the resident was incontinent of bowel and bladder and had been self-catheterizing prior to admission. Nursing notes indicated that the resident continued to self-catheterize to assist with bladder control, but there was inconsistency in documentation regarding the presence of a catheter, participation in a toileting program, and monitoring of urinary output or complications. Staff provided the resident with catheters when supplies were low, but did not document the specifics of the catheterization process or any monitoring. Interviews with nursing staff, the ADON, DON, and the Administrator revealed uncertainty about the need for physician orders and staff monitoring for self-catheterization. While some staff believed monitoring was necessary, others were unsure of the requirements. Leadership acknowledged that an order specifying catheter size, frequency, and responsibility for monitoring should have been present, and that the care plan should have included this information. Despite these expectations, the required orders and documentation were not in place during the resident's stay.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
Staff failed to provide food and liquids in the prescribed form for a resident with a physician order for a pureed diet and nectar thick liquids. The resident, who had moderate cognitive impairment, swallowing difficulties, and a diagnosis of gastro-esophageal reflux disease, was observed receiving unthickened chocolate milk and water on multiple occasions. The resident's care plan and physician orders clearly indicated the need for thickened liquids, but these were not consistently provided. Multiple staff members, including CNAs, a CMT, and LPNs, were unaware of the resident's thickened liquid requirement or did not check the diet card or physician orders before serving drinks. Staff interviews revealed a lack of awareness and communication regarding the resident's dietary needs, with several staff stating they did not know the resident was on thickened liquids or that they relied on nurses or diet cards for updates. Observations confirmed that the resident was given regular liquids, including chocolate milk and ice water, which were not thickened as ordered. The dietary manager confirmed that while the kitchen provides thickened liquids per orders, nursing staff are responsible for preparing thickened chocolate milk and water throughout the day. Despite clear orders and documentation, the resident continued to receive unthickened liquids, and staff interviews indicated ongoing confusion about the resident's dietary requirements. Facility leadership, including the DON and administrator, acknowledged that staff should follow physician orders for thickened liquids but were not aware that the orders were not being followed.
Failure to Document Wound VAC Orders and Treatments
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who was admitted with a stage 4 pressure ulcer and required a wound VAC. Upon admission, the resident's medical record did not contain complete documentation of wound assessments, wound VAC orders, or wound care treatments. Although the facility's policy required a physical skin evaluation and documentation upon admission, as well as ongoing monitoring and care planning, these steps were not fully carried out for this resident. Staff interviews revealed that the wound VAC was applied after admission and experienced issues with maintaining suction, leading to multiple dressing changes and the need to order a replacement device. Despite these interventions, there was no documentation of wound VAC orders specifying pressure settings, frequency of dressing changes, or monitoring instructions in the resident's medical record. Additionally, wound care and dressing changes performed by staff were not consistently documented, and the required wound assessment upon admission was not completed or recorded. Multiple staff members, including LPNs, the ADON, and the DON, acknowledged that documentation was lacking and that proper orders and assessments should have been present in the resident's chart. The absence of these records meant that the facility did not comply with its own policies or accepted professional standards for maintaining accurate and complete medical records for residents with wounds requiring specialized care.
Failure to Protect Resident from Verbal and Physical Abuse During Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically and verbally abused a resident during incontinence care. The resident, who had moderate cognitive impairment, anxiety disorder, fibromyalgia, and venous hypertension, was dependent on staff for hygiene and mobility. During the incident, the resident expressed refusal to be changed, became agitated, and attempted to resist care by hitting and cursing at the CNA. Despite the resident's refusal and agitation, the CNA continued to provide care, using increased force to turn and reposition the resident, and verbally yelled at the resident. Another CNA present witnessed the incident and reported that the CNA used profane language and handled the resident roughly, including slamming the resident's legs onto the bed and forcefully turning the resident by the shoulder and hip. The facility's policy prohibits all forms of abuse and requires staff to respect residents' rights to refuse care. The CNA involved admitted to using more force than usual and acknowledged that the resident was combative during care. The CNA also reported the incident to a nurse, expressing concern about the amount of force used. The other CNA present attempted to intervene by asking the CNA to leave the room multiple times, but the CNA completed the care before leaving. The incident was reported to nursing staff, and an assessment was conducted, which did not reveal new injuries but did note some older discolorations on the resident's arms. Documentation and reporting procedures were not fully followed according to facility policy. The electronic medical record did not contain documentation related to the abuse report, and the nurse who assessed the resident did not complete a progress note about the incident or the assessment. Interviews with staff indicated that they were aware of the correct procedures for reporting and documenting abuse allegations, but these procedures were not consistently implemented in this case.
Failure to Obtain, Document, and Care Plan Wound Care Orders for Multiple Residents
Penalty
Summary
The facility failed to provide care and treatment according to physician orders, resident preferences, and established standards of practice for three residents with wounds. Staff did not obtain or enter wound care orders, did not document wound care provided, and did not update care plans to reflect current wounds and treatments. For one resident with a recent hip fracture and surgical incision, staff did not transcribe hospital discharge wound care orders into the physician order sheet or treatment administration record, nor did they care plan for the hip incision and its required care. Progress notes referenced the surgical site, but there was no documentation of dressing changes or ongoing monitoring in the treatment records. Another resident with multiple injuries, including a head laceration with sutures, returned from the hospital without documented wound care orders. Staff did not contact the physician to obtain orders for the head wound, and the care plan was not updated to reflect the most recent fall and laceration. No orders or treatments related to the head laceration were documented in the medication or treatment administration records, despite ongoing monitoring and assessment of the wound in progress notes. A third resident experienced skin tears to the right elbow and left upper extremity following falls and contact with equipment. While staff cleansed and dressed the wounds and notified appropriate parties, they did not enter treatment or monitoring orders into the physician order sheet or treatment administration record. The care plan was not updated to address these wounds, and staff interviews confirmed that wound care orders were not consistently entered or documented. The facility was unable to provide a policy regarding the process for obtaining, entering, and following treatment or monitoring orders.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported immediately to facility management and to the State Survey Agency within the required timeframe. According to the facility's policy, all instances of abuse must be reported immediately to the Administrator and to the state agency no later than two hours after the allegation is made. However, in this case, a resident with a history of stroke, paralysis, dementia, and other medical conditions reported that a Certified Nurse Aide (CNA) had thrown them into bed. The allegation was made known to a Registered Nurse (RN) on the day of the incident, but the RN conducted their own investigation and determined there was no reportable occurrence, failing to notify management or the state agency as required. The resident, who was dependent on staff for mobility and transfers due to significant physical limitations, described being roughly handled by the CNA, resulting in their feet being caught in the wheelchair. The incident was relayed to a family member, who then contacted the facility. Despite the resident's report and the family member's concern, the RN did not document or escalate the allegation to the Director of Nursing (DON) or the Administrator on the day it occurred. The facility's self-report to the state agency was not made until the following day, outside the required reporting window. Interviews with facility staff confirmed that the expectation was for all allegations of abuse to be reported immediately to supervisors and to the state agency within two hours. Staff members, including CNAs, nurses, the DON, and the Administrator, all stated that immediate reporting was required by policy. The delay in reporting the allegation of abuse constituted a failure to follow both facility policy and regulatory requirements for timely reporting of suspected abuse.
Failure to Conduct Timely and Thorough Abuse Investigation
Penalty
Summary
The facility failed to document a timely and thorough investigation into an allegation of possible physical abuse involving one resident. The incident was reported to the Director of Nursing (DON) and the Administrator a day after it occurred, and the initial response did not include immediate notification or removal of the alleged perpetrator from resident contact. The investigation was limited to written statements from the involved CNA, two RNs, and did not include interviews with other staff or residents who may have been present or received care from the same staff member. The resident involved had a history of left-sided weakness and paralysis following a stroke, anxiety, depression, insomnia, dementia, and required substantial assistance for mobility and transfers. The resident alleged that a CNA had thrown them into bed, causing injury to their feet. The incident was initially investigated by an RN, who concluded there was no reportable occurrence and did not escalate the matter to facility leadership or suspend the CNA as required by policy. Facility policy required immediate action to protect residents and a comprehensive investigation, including interviews with all relevant staff and residents. However, documentation showed that these steps were not followed. The lack of timely reporting, failure to remove the alleged perpetrator, and incomplete investigation did not meet the facility's own abuse prevention and investigation standards.
Inadequate Pain Management for Resident
Penalty
Summary
The deficiency involves the failure to provide safe and appropriate pain management for a resident who required such services. The report references an event identified by surveyors, indicating that the facility did not adequately address the pain management needs of the resident. Specific details about the resident's medical history or condition at the time of the deficiency are not provided in the report. However, the lack of appropriate pain management services suggests a lapse in the facility's responsibility to ensure the resident's comfort and well-being.
Failure to Provide Adequate Pharmaceutical Services
Penalty
Summary
The deficiency involves the failure to provide pharmaceutical services to meet the needs of each resident, as well as the failure to employ or obtain the services of a licensed pharmacist. This deficiency was identified during a survey event with ID P16012, which concluded on February 6, 2025. The report does not provide specific details about the residents affected or the specific circumstances leading to the deficiency, but it highlights a lapse in ensuring that pharmaceutical services were adequately provided and managed by a licensed professional.
Significant Medication Errors Identified
Penalty
Summary
The report identifies a deficiency related to significant medication errors affecting residents. The event, referenced by ID P16012, highlights that residents were not free from significant medication errors, which is a critical aspect of their care. The deficiency was noted during a survey with an exit date of February 6, 2025. However, specific details about the actions or inactions leading to the medication errors, as well as the medical history or condition of the residents involved, are not provided in the report.
Resident Moved Inappropriately by Staff Member
Penalty
Summary
The facility failed to ensure that all residents were treated in a dignified manner, as evidenced by an incident involving a resident who was moved inappropriately by a staff member. The resident, who had multiple diagnoses including bipolar disorder, anxiety disorder, dementia with behavioral disturbances, cerebrovascular disease, COPD, and metabolic encephalopathy, was observed to have severe cognitive impairment and required supervision for various activities. The resident had a history of voluntarily putting themselves on the floor, which was documented in their care plan. On the day of the incident, a Certified Medication Technician (CMT) witnessed the resident lower themselves to the floor inside the nurses' station. A Certified Nurse Aide (CNA) then rolled the resident onto their back and pulled them by their feet approximately ten feet into the day room. The CNA explained that they could not lift the resident due to the narrow passage and potential danger of lifting the resident in that position. The CNA was concerned about the safety of other residents and felt unable to leave the area to seek assistance. Interviews with various staff members, including Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs), and the Director of Nursing (DON), consistently indicated that pulling a resident by their legs was considered disrespectful and inappropriate. The staff acknowledged the resident's tendency to fall and the need for constant supervision, but emphasized that the method used to move the resident was not acceptable. The facility's policy on resident rights underscored the importance of treating residents with dignity and respect, which was not upheld in this incident.
LPN Worked Without Valid License
Penalty
Summary
The facility failed to ensure that all licensed nurses had the necessary competencies and valid licenses to care for residents, as evidenced by the employment of an LPN whose nursing license was no longer valid in the State of Missouri. The facility's policy required verification of licenses and background checks before allowing staff to work with residents. However, LPN C continued to work at the facility after their New Mexico-issued nursing license was placed on probationary status and was no longer a multi-state license due to issues such as misappropriation of property and errors in medication administration. The Business Office Manager (BOM) was responsible for conducting background checks and initially verified LPN C's multi-state LPN license from New Mexico, which was valid at the time of hire. However, subsequent checks revealed that the license had been suspended. Despite the facility's policy to screen employees thoroughly, the lapse in monitoring the ongoing validity of LPN C's license led to the deficiency, as the LPN continued to work without a valid license, potentially compromising resident care.
Misappropriation of Resident Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, which were under the control of facility staff. This deficiency was identified when discrepancies in the controlled medication counts were discovered for four residents. The issue arose when a Certified Medication Technician (CMT) noticed that medications were signed out but not administered, and the times recorded for administration were incorrect. Further investigation revealed that several doses of controlled medications were missing, and some were signed out without being administered. The situation was exacerbated by the actions of an LPN who appeared impaired and was unable to properly count or manage the controlled medications. This LPN had signed out medications at incorrect times and without proper orders, leading to missing doses for multiple residents. The residents involved had various medical conditions, including dementia, diabetes, fractures, Alzheimer's disease, and chronic pain, requiring careful management of their medications. Interviews with staff revealed that the facility did not conduct regular audits of controlled medications, and there was a lack of proper documentation and oversight in the medication administration process. The failure to adhere to protocols for counting and documenting controlled substances contributed to the misappropriation of medications, leaving residents without their necessary treatments.
Failure to Provide Adequate Pain Management Due to Medication Unavailability
Penalty
Summary
The facility failed to maintain an adequate supply of prescribed pain medications and access to emergency medications, resulting in three residents not receiving their medications as ordered. Resident #7, who had diagnoses including congestive heart failure, kidney disease, and depression, did not receive Lidocaine patches and acetaminophen due to unavailability. The staff did not document any contact with the physician regarding the missed medications, and the resident's pain management was compromised. Resident #8, diagnosed with Parkinson's disease, type 2 diabetes, and polyosteoarthritis, also experienced a lack of pain management due to unavailable acetaminophen. The resident reported increased pain and discomfort, rating it as a 6 on a scale of 0-10. Despite the resident's complaints, the staff failed to contact the physician about the medication unavailability, and the resident's pain management needs were not met. Resident #9, with severe cognitive impairment and chronic pain, did not receive Lidocaine patches and hydrocodone as prescribed due to the facility running out of these medications. The resident reported pain and difficulty sleeping, yet the staff did not notify the physician about the medication shortages. Interviews with staff revealed systemic issues with medication ordering and access, particularly for agency staff who did not have access to the emergency medication kit.
Inconsistent Documentation of Controlled Substances
Penalty
Summary
The facility failed to ensure consistent counting and reconciliation of controlled substances due to inadequate documentation practices by staff. The October 2024 Controlled Substance Shift Change Log revealed multiple instances where staff did not initial the oncoming and off-going counts or document the total number of medication packages across four medication carts. These lapses occurred on various dates and shifts, indicating a systemic issue in maintaining accurate records of controlled substances. Interviews with staff, including LPNs and CMTs, confirmed that the expected procedure was for both oncoming and off-going staff to count controlled medications, document the total number of medication packages, and initial the shift change log. However, several staff members were unaware of the lapses in documentation, and there was no regular audit process in place to ensure compliance with these procedures. This lack of oversight contributed to the ongoing deficiencies in the facility's pharmaceutical services. The Assistant Director of Nursing and the Assistant to the Administrator acknowledged the importance of counting and documenting controlled medications at each shift change. They also noted that discrepancies should be reported immediately to the Director of Nursing or Administrator. Despite these expectations, the facility did not have a system to audit the controlled medication logs regularly, leading to repeated failures in documentation and reconciliation of controlled substances.
Medication Errors Due to Lack of Glucometer Test Strips
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors due to a lack of glucometer test strips, which are essential for conducting blood sugar checks. This deficiency affected three residents with type 2 diabetes, who were unable to receive their physician-ordered insulin because their blood sugar levels could not be tested. The facility's policy required blood sugar testing before insulin administration, but the absence of test strips led to missed doses of insulin for these residents. Resident #3, who had moderate to severe cognitive impairment and a diagnosis of diabetes, did not receive several doses of insulin as ordered on February 2, 2025, because staff could not perform the necessary blood sugar checks. The staff noted the unavailability of the test strips and did not notify the physician about the missed doses or seek guidance on insulin administration. Similarly, Resident #4, who was cognitively intact, missed a dose of Lantus insulin on February 1, 2025, due to the same issue, although the physician was notified, and the resident showed no signs of hypo/hyperglycemia. Resident #6, with moderate cognitive impairment and a diabetes diagnosis, also experienced missed insulin doses on January 24, 2025, and February 1, 2025, due to the unavailability of test strips. The staff failed to contact the physician for guidance on the missed dosages. Interviews with facility staff revealed that the issue of running out of test strips was known, but there was a lack of communication and follow-up to resolve the problem promptly. The Director of Nursing had not consistently audited the Medication Administration Records, and the responsibility for ordering supplies was not effectively managed, contributing to the deficiency.
Failure to Administer Antibiotics and Monitor Wound Dressing
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who had undergone a toe amputation due to osteomyelitis. Upon the resident's return from the hospital, the facility did not administer the prescribed antibiotic, linezolid, in a timely manner, resulting in a delay of approximately 33 hours after the last hospital-administered dose. This delay was due to the medication being unavailable and the need for prior authorization from the resident's insurance. The Director of Nursing authorized a five-day supply to bridge the gap, but the initial delay in administration was significant. Additionally, the facility did not adequately monitor the condition of the resident's wound dressing following the toe amputation. Despite hospital discharge instructions to leave the dressing intact until a follow-up appointment, staff failed to document the condition of the dressing or any changes in the resident's wound status. On one occasion, a nurse observed the dressing was saturated with serosanguinous drainage but did not document this observation or ensure follow-up with the podiatrist as instructed by the primary care physician. The lack of documentation and communication among staff members further exacerbated the situation. Several nurses and the Assistant Director of Nursing observed issues with the dressing but did not document these observations or take appropriate action. The facility's failure to monitor and document the resident's wound condition and the delay in administering antibiotics contributed to the deficiency in providing care according to professional standards and the resident's needs.
Deficiency in Pressure Ulcer Management
Penalty
Summary
The facility failed to provide adequate wound care and monitoring for a resident, leading to a deficiency in pressure ulcer management. The resident, who had a history of dementia, type II diabetes mellitus with nephropathy, and other conditions, was readmitted to the facility with open areas on the buttocks. Despite the presence of these pressure ulcers, the facility staff did not document complete wound assessments or obtain timely physician orders for treatment. The facility's policy required thorough documentation of wound information and notification of appropriate personnel for new pressure ulcers, which was not adhered to in this case. Upon the resident's readmission, the admitting nurse did not conduct a comprehensive skin assessment or obtain treatment orders for the pressure ulcers. The resident's progress notes and physician orders lacked documentation of a treatment plan for the left buttock, and there was a delay in obtaining orders for the right buttock. The Assistant Director of Nursing (ADON) and other staff members attempted to remove a hospital-applied dressing, which resulted in further skin damage due to improper removal techniques. The ADON and Director of Nursing (DON) were not promptly informed of the resident's condition, leading to inadequate initial wound care. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's pressure ulcers. The ADON was not notified of the resident's open areas upon admission, and the DON acknowledged that a full wound assessment was not conducted. The facility's failure to follow its wound care protocol and ensure timely and appropriate treatment orders contributed to the deficiency in pressure ulcer management for the resident.
Failure to Notify Resident and Family of Changes
Penalty
Summary
The deficiency involves a failure to immediately inform the resident, the resident's doctor, and a family member about situations affecting the resident, such as injury, decline, or room changes. This oversight was identified in event ID 7LS712, with an exit date of 06/04/24, and is documented under citation MO00235482. The report does not provide specific details about the resident's medical history or condition at the time of the deficiency, nor does it elaborate on the specific circumstances or events that led to the failure in communication.
Failure to Provide Care According to Orders and Preferences
Penalty
Summary
The deficiency involves the failure to provide appropriate treatment and care according to the orders, preferences, and goals of the residents. The report references an event identified by surveyors, indicated by event ID 7LS712, which highlights this failure. Specific details about the residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report. The deficiency is documented under identifiers MO00235482 and MO00236961.
Deficiency in Safeguarding Resident Information
Penalty
Summary
The report identifies a deficiency related to the safeguarding of resident-identifiable information and the maintenance of medical records. The facility failed to adhere to accepted professional standards in handling and securing medical records for each resident. This deficiency was noted during an event with the ID 7LS12, which concluded on the exit date of 06/04/24. The specific details of the actions or inactions leading to this deficiency are not provided in the report.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by an incident involving a Certified Nurses Assistant (CNA) identified as CNA B and a resident. The resident, who was cognitively intact and had diagnoses including Parkinson's disease and dementia, reported that CNA B spoke to them in a rude, loud, and disrespectful manner. The incident occurred when the resident requested assistance to go to bed and was met with frustration and inappropriate comments from CNA B. The resident's body language during interviews indicated distress, as they appeared reserved and avoided eye contact. Multiple staff members provided statements regarding the incident and CNA B's behavior. A Certified Medication Technician (CMT) witnessed CNA B being loud and disrespectful, and reported the behavior to a Registered Nurse (RN), who acknowledged the issue but did not take further action. Other staff members, including another CMT and a CNA, corroborated the resident's account, noting that CNA B had a history of being rude and disrespectful to residents. Despite these reports, the facility's administrative staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, claimed they were unaware of any inappropriate behavior by CNA B. The facility's policy on abuse, neglect, and mistreatment did not specifically address treating residents with dignity and respect, which may have contributed to the oversight in addressing CNA B's behavior. The lack of documentation in the resident's nurses' notes regarding the incident further highlights the facility's failure to address and document issues related to resident dignity and respect. This deficiency in ensuring respectful treatment of residents was not adequately reported or addressed by the facility's staff and administration.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to notify the physician and the resident's representative in a timely manner following a fall with injury involving a resident. The resident, who had severe cognitive impairment and a history of falls, experienced a fall at 3:00 A.M. on 04/30/24, resulting in a bump, laceration on the forehead, and skin tears on the left wrist and arm. Despite the injuries, the staff did not document any notification to the resident's physician or responsible party immediately after the incident. The resident's fall was initially documented by LPN A, who was on duty during the night shift. However, there was no record of the physician or family being informed about the fall at that time. Subsequent documentation by LPN B and LPN C also failed to indicate that the necessary notifications were made. It was only later, during the day shift, that the resident's complaints of pain were reported to the on-call Nurse Practitioner, who ordered x-rays. Still, the resident's family remained uninformed about the fall until much later. Interviews with various staff members, including the resident's physician, Nurse Practitioners, and the facility's administration, revealed a lack of immediate communication following the fall. The physician and family were not promptly notified, which was against the facility's policy. The staff acknowledged that the physician and family should have been contacted immediately after the fall, and the notifications should have been documented in the resident's medical records.
Failure to Conduct Timely Neurological Checks and Administer Medications
Penalty
Summary
The facility failed to provide care per standards of practice in two significant instances involving two residents. In the first case, the facility did not complete or document neurological checks timely after a resident experienced a fall with a head injury. The resident, who had severe cognitive impairment and a history of falls, fell from a wheelchair and sustained a head injury. Although initial neurological checks were started, subsequent checks were not documented as required by the facility's policy. Additionally, there was a lack of communication among nursing staff regarding the fall and the necessary monitoring, which led to a delay in addressing x-ray results that showed a fracture. In the second case, the facility failed to complete an ordered urinalysis (UA) timely and did not administer medications to treat a urinary tract infection (UTI) as ordered for another resident. The resident, who had dementia and was frequently incontinent, showed signs of a fever and was ordered a UA with culture and sensitivity. However, there was no documentation of the UA being completed or the results being obtained. Later, when the resident's condition worsened, a new UA was ordered, and antibiotics were prescribed, but there were delays and missed doses in administering the medication. These deficiencies highlight significant lapses in the facility's adherence to care protocols and communication among staff, which are critical in ensuring timely and appropriate medical interventions for residents. The lack of timely neurological assessments and failure to administer prescribed medications as ordered contributed to inadequate care for the residents involved.
Incomplete Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure complete and accurate documentation of a resident's medical records following a fall with injury. The incident involved a resident with severe cognitive impairment and a history of falls, who fell and sustained injuries including a laceration on the forehead and a skin tear on the left wrist and upper arm. Despite the resident's complaints of left leg pain and subsequent x-ray orders revealing a high impacted fracture of the left femur, the facility staff did not document the x-ray results or the actions taken following the receipt of these results. The report highlights several lapses in documentation by the nursing staff. LPN A, who was on duty during the fall, documented the initial assessment but failed to follow up with further documentation regarding the resident's condition or the x-ray results. LPN B, who took over the shift, was unaware of the x-ray order until the end of the shift and did not document any assessments or notifications. RN E, who was on the subsequent shift, only became aware of the x-ray results late in the evening and did not document any follow-up actions or the resident's discharge from the facility. Interviews with the facility staff, including the Interim DON and the Administrator, confirmed that the charge nurse is responsible for documenting fall assessments, neurological assessments, and any changes in the resident's condition. However, the lack of documentation regarding the x-ray results and the resident's discharge indicates a failure to adhere to these responsibilities, resulting in incomplete and inaccurate medical records for the resident.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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