Tiffany Springs Rehabilitation & Health Care Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 9191 N Ambassador Drive, Kansas City, Missouri 64154
- CMS Provider Number
- 265863
- Inspections on file
- 36
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Tiffany Springs Rehabilitation & Health Care Cente during CMS and state inspections, most recent first.
A resident with COPD, CHF, and mobility difficulties had a physician-signed Out of Hospital DNR documented in the EMR and a care plan stating that advance directives would be honored. When the resident was found unresponsive in a wheelchair without apparent respirations or pulse, an LPN, who later reported panicking, performed a sternal rub, found no pulse, assisted with moving the resident to the floor, and initiated CPR without first checking the resident’s code status in the EMR or the crash cart notebook, contrary to facility policy. After two cycles of chest compressions, a pulse was detected, and EMS arrived, recorded vital signs, and transported the resident to the hospital. Staff interviews confirmed that code status is clearly available in the EMR and on the crash cart list and that the expectation is to verify code status before starting CPR.
A resident admitted with a left ankle fracture and a soft cast, and identified as at risk for pressure ulcers, later had a CAM boot applied with orders to keep it on except for hygiene. Nursing documentation repeatedly noted no skin issues other than a Stage I pressure injury on the right great toe, and staff (including an RN, LPN, and CNA) reported they never removed the boot to assess skin or provide hygiene, despite the resident’s ongoing complaints of significant foot pain. The resident stated the boot and underlying sock were never removed for more than two weeks and that staff told them they could not take the boot off. When the resident finally returned to the orthopedic physician after more than three weeks, a large medial ankle/foot ulcer was found, and wound clinic evaluation documented a large unstageable wound with eschar under the CAM boot, which was attributed to the boot not being removed for three weeks. Subsequent surgery revealed a full-thickness ulcer with eschar, partial tendon exposure, and associated hardware infection requiring debridement and hardware removal.
A resident with a signed DNR order did not have their code status accurately updated in the physician orders or medical record banner. When the resident was found unresponsive, staff could not verify the DNR status and performed CPR, with EMS continuing life-saving measures. The failure to update and communicate the resident's code status led to the deficiency.
The facility failed to provide timely lab testing and results for three residents, leading to significant health issues. Two residents were hospitalized with septic shock due to untreated UTIs, as the facility did not carry out lab orders despite repeated communications from hospice staff. Another resident was without psychotropic medication for fourteen days because the pharmacy required lab results, which the facility failed to obtain. This resulted in increased stress and sleep disturbances for the resident.
The facility failed to provide timely laboratory services, resulting in a resident being without psychotropic medication for two weeks due to missing lab results. Several residents with UTI symptoms did not receive timely urine cultures, leading to one resident's hospitalization for sepsis. The facility also lacked necessary lab supplies, further delaying care.
The facility failed to maintain safe food handling practices and a sanitary kitchen environment. Observations showed staff using the same gloves for multiple tasks, leading to potential contamination. The kitchen had significant cleanliness issues, including greasy surfaces and food debris. Staff interviews revealed a lack of training in food safety practices, and the Dietary Manager acknowledged the unsanitary conditions.
The facility failed to provide properly prepared pureed food to residents on a pureed diet. Observations revealed that the pureed sausage served was dry and crumbly, requiring chewing, contrary to the required smooth, mashed potato consistency. Cook1 admitted to not blending the sausage long enough, leading to the deficiency.
The facility failed to provide adequate pain management for three residents, leading to significant deficiencies in care. A resident with severe pain did not receive timely medication, despite clear communication of her pain. Another resident experienced a five-day delay in receiving effective pain management due to an expired prescription and lack of follow-up. A third resident with chronic pain syndrome did not receive scheduled pain medication consistently, affecting her daily activities. Interviews revealed a lack of communication and failure to ensure medication availability.
A resident with chronic pain conditions did not receive prescribed pain medications due to unavailability, and the facility failed to notify the physician. The resident's Norco and lidocaine patch were not administered on several occasions, and there was insufficient documentation of physician notification. Interviews with staff revealed a lack of communication and adherence to protocol, resulting in inadequate pain management for the resident.
A facility failed to conduct a timely PASARR Level II screening for a resident who returned from a psychiatric facility with a new diagnosis of major depressive disorder with severe psychotic symptoms. Despite receiving psychiatric services, the necessary screenings were not initiated, as confirmed by the Social Services Designee and the DON, highlighting a lapse in the facility's process for handling significant changes in residents' conditions.
A facility failed to create a comprehensive care plan for a resident with an ICD, despite the resident's cognitive intactness and specific health needs. The care plan lacked focus on ICD-related interventions, and facility leaders believed no specific plan was needed, assuming staff would call 911 if necessary. This oversight was identified during a review of the resident's EMR.
A resident with Parkinson's and dementia experienced a decline in ADL abilities, which the facility failed to address. Despite being assessed as needing minimal assistance, observations showed the resident struggled with personal hygiene and grooming. Staff interviews confirmed the resident required more help than previously assessed, indicating a need for reassessment of care needs.
A resident with emphysema was observed with an oxygen e-tank standing unsupported against the wall, while connected to an oxygen concentrator. The MDSC confirmed the e-tank should have been secured in its carrier, and the DON stated that e-tanks are to be secured.
A resident with a PICC line for IV antibiotics had their dressing unchanged for 15 days, contrary to the facility's policy of changing it every seven days. The dressing was observed to be partially detached, increasing infection risk. The ADON confirmed the oversight.
A resident with rheumatoid arthritis, chronic pain syndrome, and anxiety did not receive timely administration of medications due to prescription changes, pharmacy delays, and lack of communication with the physician. The facility staff, including the DON and NP, were not adequately informed of the missed doses, leading to a failure in ensuring the resident received her necessary medications.
A facility failed to document the death of a resident and did not include a physician order to release the body. The resident, who had a history of lumbar fracture, congestive heart failure, and COVID-19, experienced respiratory distress and stabilized after oxygen intervention. Despite the family's decision to avoid hospitalization, there was no further documentation after 4:00 AM. Interviews revealed the resident's rapid decline and the absence of hospice care before death. The Medical Director acknowledged the lack of documentation and the missing release order.
A CNA at a LTC facility recorded two videos of a resident without consent, violating the resident's right to privacy. The resident, who had severe cognitive impairment, was filmed in undignified situations. The facility lacked clear policies and training on resident rights and cell phone use, contributing to the incident.
A resident in a long-term care facility was found unresponsive and without a pulse, but CPR was not initiated immediately due to an LPN's incorrect assumption about the resident's code status. Despite being informed by CNAs that the resident was a full code, the LPN delayed CPR until the DON arrived and confirmed the status. The LPN, an agency nurse, had not received proper orientation on emergency procedures, contributing to the delay in life-saving measures.
Failure to Honor DNR Order and Follow CPR Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented Do Not Resuscitate (DNR) order and to follow its own Cardiopulmonary Resuscitation (CPR) and Resident Rights policies. The resident, who was their own responsible party, had diagnoses including COPD, CHF, pain, and difficulty walking, and had an Out of Hospital DNR form signed by both the resident and the primary care physician in the electronic medical record. The resident’s comprehensive care plan stated that the resident was not near end of life but that advance directives would be honored. The facility’s CPR policy required clinical staff to verify code status in the clinical record when a resident was found unresponsive and not breathing normally, and if the resident was a DNR, to notify the attending provider. The Resident Rights policy stated that residents have the right to self-determination, autonomy, and choice regarding receipt of care. On the day of the incident, an LPN entered the resident’s room to provide skin treatment and found the resident in a wheelchair, unresponsive, with head bent down, and without apparent breathing or pulse. The LPN performed a sternal rub without response, checked for a pulse at the wrist and neck and felt none, then, with assistance from other staff, moved the resident to the floor and initiated chest compressions. The LPN completed 30 compressions, rechecked for a pulse, found none, and performed another 30 compressions, after which a pulse was detected. Emergency Medical Services arrived, documented vital signs including a heart rate of 83 bpm and blood pressure of 146/60, and transported the resident to the hospital. The LPN later stated that they panicked, did not check the resident’s code status in the electronic medical record or the crash cart notebook before starting CPR, and acknowledged that code status should have been verified first. Other nursing staff and leadership confirmed that code status is available in the EMR and in a crash cart notebook and that staff are expected to check code status prior to initiating CPR.
Failure to Monitor Skin Under CAM Boot Resulting in Unstageable Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development of an unstageable pressure injury under a removable medical device for one resident. The facility’s own skin policy required licensed nurses to evaluate skin integrity on admission, weekly, and with significant changes, and required CNAs to observe skin during ADLs and report changes so that licensed nurses could initiate preventive or treatment interventions. On admission from the hospital, the resident had a left ankle fracture, a soft cast/splint applied by the orthopedic surgeon, and no documented skin lesions other than a Stage I pressure injury on the right great toe that was present on admission. The admission MDS identified the resident as at risk for pressure ulcers, with partial to moderate assistance needs for ADLs and diagnoses including ankle fracture, muscle weakness, anxiety, stroke, and dementia. Early nursing documentation repeatedly stated there were no other skin issues besides the right great toe. The resident initially had a soft cast that was not to be removed until an orthopedic follow-up. At the follow-up, the orthopedic physician removed the soft cast and placed a CAM boot on the left ankle, with orders that the boot be left on at all times except for hygiene. Despite this order, multiple nursing staff, including an RN and an LPN, reported they never removed or opened the boot to assess the skin or provide hygiene, stating they believed they should not open it if the order was to leave it in place. A CNA reported the resident complained of a lot of pain in the left foot and that she loosened the boot strap once to assist with pain relief but did not remove the boot. The resident stated that after arriving at the facility, the CAM boot was never removed until the return visit to the physician, that a sock under the boot was left in place for more than two weeks, and that facility staff told the resident they could not take the boot off. The resident reported significant ankle pain but could not distinguish whether it was from the skin or the surgery. When the resident eventually returned to the orthopedic physician after more than three weeks instead of the ordered two-week follow-up, the physician found a medial foot/ankle ulceration measuring approximately 3–6 cm with a fibrous base and mildly erythematous edges. The orthopedic surgeon and wound clinic RN attributed the open wound to the CAM boot not being removed for three weeks, and the wound clinic RN documented a large unstageable wound with eschar on the left ankle/foot measuring 3.3 cm by 3.1 cm by 0.1 cm. The DON acknowledged that, with an order to remove the boot for hygiene, staff should have opened the boot and checked the skin every shift and admitted that the facility did not check the resident’s skin and that this was wrong. The orthopedic surgeon stated it was unacceptable that the boot was not removed and the skin was not checked for three weeks. Subsequent operative documentation showed the resident developed a full-thickness ulcer to the fat layer with large eschar and partial tendon exposure, associated with a hardware infection in the left ankle that required irrigation, debridement, hardware removal, and preparation of the wound bed for a skin graft. The sequence of events shows that, despite the resident’s identified risk for pressure ulcers, the presence of a removable CAM boot, and ongoing complaints of pain, facility staff did not perform periodic skin checks under the device for more than 20 days. Nursing notes during this period continued to document no skin issues other than the right great toe, and staff interviews confirmed that the boot was not removed for skin assessment or hygiene. The NP and Unit Manager both stated they would have expected staff to open the boot and check the skin and pulses, and the Unit Manager stated that an order to check the skin under the boot was not necessary. The failure to follow the facility’s skin monitoring policy and to assess the skin under the CAM boot as ordered for hygiene led to the development of an unstageable pressure injury and subsequent complications documented in the medical record and operative reports.
Failure to Honor Resident's DNR Due to Incomplete Medical Record Update
Penalty
Summary
Facility staff failed to honor a resident's Do Not Resuscitate (DNR) advanced directive when they performed Cardiopulmonary Resuscitation (CPR) and notified Emergency Medical Services (EMS) to complete all life-saving measures. This occurred because the DNR order, although signed by the resident and uploaded to the miscellaneous section of the medical record, was not accurately entered into the physician orders or reflected in the resident's medical record banner. As a result, staff were unable to quickly verify the resident's code status during the emergency. The resident involved was on hospice services, had a diagnosis of lung cancer and depression, and was dependent on staff for all activities of daily living. The resident had intact cognitive skills and had signed a DNR order prior to the incident. However, the admission record did not list an advance directive, and the electronic medical record did not indicate the DNR status. When the resident was found unresponsive, staff checked the available records and, not finding the DNR status, initiated CPR and called EMS, who continued resuscitation efforts until the resident was pronounced deceased. Interviews with staff revealed that the process for updating code status was not consistently followed. Social services had uploaded the DNR and notified nursing to change the code status, but the nurse responsible was interrupted and did not complete the entry. The code status was not updated in the physician orders or on the code status roster, leading to confusion during the emergency. Staff relied on the code status report and the medical record banner, both of which did not reflect the resident's DNR status, resulting in the failure to honor the resident's documented wishes.
Failure to Provide Timely Lab Testing and Results
Penalty
Summary
The facility failed to provide timely lab testing and results for three residents, leading to significant health issues. Two residents were admitted to the hospital with septic shock due to untreated urinary tract infections (UTIs). The facility did not carry out lab orders for one resident, despite the hospice nurse providing new orders for tests such as TSH and C-diff. The resident's condition deteriorated, resulting in hospitalization for sepsis, pneumonia, and a UTI. The resident's representative and hospice staff had repeatedly communicated concerns about the resident's condition and the lack of lab results, but the facility did not act promptly. Another resident experienced a delay in receiving lab results for a UA, which was crucial for monitoring their condition due to a history of UTIs and sepsis. Despite the resident and their spouse requesting a UA to check for a bladder infection, the lab specimen was mishandled, and results were delayed. This resident was also hospitalized for a UTI with sepsis, highlighting the facility's failure to ensure timely lab testing and results. A third resident was without their psychotropic medication for fourteen days because the pharmacy required lab results before dispensing the medication. The facility failed to obtain the necessary lab tests, leaving the resident without essential medication. The resident experienced increased stress and sleep disturbances due to the lack of medication. The facility's inability to coordinate lab services and ensure timely testing and results significantly impacted the residents' health and well-being.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for its residents, resulting in significant delays in obtaining and reporting lab results. This deficiency was evident in the case of a resident who was without their psychotropic medication, clozapine, for fourteen days because the pharmacy required lab results before dispensing the medication. Despite multiple orders for weekly complete blood count with differential (CBCD) labs, the facility did not ensure these were completed, leading to the resident experiencing increased stress, insomnia, and physical discomfort due to the lack of medication. Additionally, the facility did not ensure timely collection and reporting of urine cultures for several residents showing signs and symptoms of urinary tract infections (UTIs). Multiple residents, including those with severe cognitive impairments and those receiving end-of-life hospice care, were affected by the facility's failure to obtain necessary lab tests. In one instance, a resident's condition deteriorated to the point of hospitalization for sepsis and pneumonia, with the hospital identifying a severe infection that had not been addressed due to the lack of timely lab results. The facility also failed to maintain adequate laboratory testing supplies, such as urine specimen containers, which further hindered the ability to collect necessary samples. This lack of supplies, combined with the failure to follow up on lab orders and results, contributed to the facility's inability to meet the residents' healthcare needs effectively. The deficiency in laboratory services was compounded by poor communication and coordination between the facility, the laboratory, and the pharmacy, leading to significant delays in treatment and care for the residents involved.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure safe food handling practices, proper labeling, dating, and sealing of food in cold storage, and maintaining a clean and sanitary kitchen environment. Observations revealed that Cook1 was preparing food while wearing the same pair of gloves, touching various surfaces and utensils, and handling food without changing gloves. This practice was observed multiple times, indicating a lack of adherence to proper hand hygiene and glove usage policies. Further observations of the kitchen environment showed significant cleanliness issues. The two-compartment vegetable prep sink had romaine lettuce in one side and dirty blender parts in the other. The standing mixer was uncovered and had dried food on the splash guard. Bulk food tubs were greasy and had food debris, and the walk-in refrigerator and freezer had food debris, cardboard pieces, and ice build-up. The kitchen floor was greasy, with stained grout and food debris pushed against the baseboards. Appliances and shelves were also found to be greasy and covered in food debris. Interviews with kitchen staff revealed a lack of awareness and training regarding safe food handling practices. Cook3 and Cook2 admitted to using gloved hands to handle food without changing gloves or using utensils, and they could not recall receiving food safety education. The newly hired Dietary Manager acknowledged the unsanitary conditions and was in the process of creating new cleaning schedules, but the issues persisted at the time of the survey.
Improper Preparation of Pureed Diet
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received food prepared in the appropriate pureed form. Observations during a kitchen tray line inspection revealed that the pureed breakfast sausage served to residents was dry, crumbly, and had a ground texture rather than the required smooth, mashed potato consistency. This inconsistency in food texture was confirmed during an evaluation of a test tray with the Dietary Manager, who acknowledged that the pureed sausage was not prepared correctly and required chewing to be swallowed. The deficiency was attributed to Cook1, who admitted to not blending the sausage long enough to achieve the desired smooth texture. The facility's recipe for pureed sausage links specified that the ingredients should be blended until a smooth, mashed potato consistency was reached, which was not adhered to in this instance. The failure to properly prepare the pureed sausage had the potential to cause issues such as choking, aspiration, malnutrition, weight loss, or dissatisfaction with meals for the residents on a pureed diet.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to significant deficiencies in care. Resident 107, who was cognitively intact and experiencing severe pain, did not receive timely pain medication despite having a documented pain level of 10. The resident expressed ongoing pain and a desire for hospice care due to inadequate pain management. Interviews with the Director of Nursing (DON) and Nurse Practitioner (NP) revealed a lack of communication and failure to schedule pain medication appropriately, despite the resident's clear communication of her pain. Resident 82, who was also cognitively intact, experienced a delay in receiving effective pain management for five days. The resident's pain medication prescription had expired, and there was a lack of follow-up to obtain a new prescription. The resident reported significant pain and a lack of timely intervention, which was confirmed by staff interviews. The DON acknowledged the absence of a pain management policy and the failure to document follow-up on the resident's pain management. Resident 4, with a history of rheumatoid arthritis and chronic pain syndrome, did not receive scheduled pain medication consistently. The resident reported daily pain and missed doses of her prescribed medication, which affected her daily activities. Interviews with the DON and NP highlighted a lack of communication and failure to ensure the availability of pain medication. The NP was unaware of the missed doses and emphasized the importance of notifying him to prevent such occurrences. The facility's failure to manage pain effectively for these residents demonstrates a significant deficiency in care.
Failure to Notify Physician of Unavailable Pain Medications
Penalty
Summary
The facility failed to notify the physician when pain medications were unavailable for a resident, leading to missed doses of prescribed pain management. The resident, who was moderately cognitively impaired, suffered from chronic pain conditions including polymyalgia rheumatica, rheumatoid arthritis, and chronic pain syndrome. Despite having orders for Norco and a lidocaine patch, the medications were not administered on multiple occasions due to unavailability, and there was insufficient documentation to confirm that the physician was notified of these missed doses. Interviews with the facility's staff, including the Director of Nursing, Infection Preventionist/Assistant Director of Nursing, and Nurse Practitioner, revealed that the expected protocol of notifying the physician and documenting follow-up actions was not followed. The Nurse Practitioner was unaware of the missed doses and stated that he would have taken necessary actions to ensure the resident received the required pain medication. The lack of communication and documentation contributed to the resident not receiving adequate pain management.
Failure to Conduct Timely PASARR Level II Screening
Penalty
Summary
The facility failed to ensure a resident, who initially had a negative Preadmission Screening and Resident Review (PASARR) Level I, was accurately and timely referred for a PASARR Level II after experiencing a significant change in status with a new diagnosis of serious mental illness. The resident, identified as R29, was admitted with acute heart failure and later placed on a psychiatric hold, returning with a diagnosis of major depressive disorder with severe psychotic symptoms. Despite receiving psychiatric services upon return, a new Level I PASARR Screen was not conducted, which was necessary due to the change in the resident's mental health status. Interviews revealed that the facility lacked a policy on PASARR, and the Social Services Designee (SSD) acknowledged the oversight, stating that a new Level I and subsequent Level II screening should have been initiated upon the resident's readmission. The Director of Nurses (DON) confirmed that the resident should have been treated as a new admission following the psychiatric hospital stay, indicating a lapse in the facility's process for handling significant changes in residents' conditions.
Failure to Develop ICD Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, patient-centered care plan for a resident with an Implantable Cardioverter Defibrillator (ICD). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was admitted with diagnoses including chronic heart failure and an ICD. Despite these conditions, the care plan did not include any focus area or interventions related to the ICD, which is crucial for managing the resident's health needs. The deficiency was identified during a review of the resident's electronic medical record (EMR), which showed no mention of the ICD in the care plan. The facility's cardiac nurse practitioner had seen the resident for a cardiac follow-up, and plans for ICD interrogation were discussed with the nursing staff. However, during an interview, the Medical Director and the Director of Nursing stated that the resident did not need a specific care plan for the ICD, as staff would know to call 911 if an issue arose. This oversight in care planning could potentially lead to harm, as it does not address the specific precautions and interventions necessary for residents with ICDs.
Resident's Decline in ADL Abilities Not Addressed
Penalty
Summary
The facility failed to maintain the current abilities of a resident, identified as R80, in performing activities of daily living (ADLs). R80, who was admitted with diagnoses including Parkinson's disease, dementia, and major depressive disorder, was observed to have declined in self-care abilities. Despite being coded as independent to needing set-up assistance for ADLs in the Minimum Data Set (MDS), observations revealed that R80 struggled with personal hygiene tasks such as shaving and nail care. Interviews with staff, including a Certified Nurse Assistant (CNA) and the Assistant Director of Nursing (ADON), confirmed that R80 required more assistance than previously assessed, indicating a decline in his ability to perform ADLs independently. The resident was found with unkempt hair, long and dirty fingernails, and a soiled appearance, suggesting inadequate grooming and personal care. The ADON acknowledged that R80 needed grooming assistance and a reassessment of his care needs. Despite the resident's insistence on performing ADLs independently, staff interviews revealed that he required more help than he was receiving. The Director of Nursing (DON) and MDS Coordinators also recognized the need for a reassessment to accurately reflect R80's current abilities, as his previous assessments did not align with his present condition.
Unsafe Storage of Oxygen E-Tank
Penalty
Summary
The facility failed to safely store an oxygen emergency tank (e-tank) for a resident who was reviewed for respiratory care. The resident, who was admitted with a diagnosis of emphysema, was observed asleep in a wheelchair and connected to an oxygen concentrator via nasal cannula tubing. During the observation, the e-tank was found standing against the wall unsupported, with the oxygen carrier nearby. The Minimum Data Set Coordinator confirmed that the e-tank should have been in the carrier and was indeed unsupported. The Director of Nursing also stated that e-tanks are required to be secured.
Failure to Change PICC Line Dressing Timely
Penalty
Summary
The facility failed to ensure the timely change of an occlusive dressing on a peripherally inserted central catheter (PICC) line for a resident receiving intravenous (IV) antibiotics. The facility's policy required that the dressing be changed every seven days to prevent infection. However, for one resident, the dressing was observed to be dated 15 days prior, indicating it had not been changed as required. This oversight was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that the dressing was not occlusive and should have been changed every seven days. The resident in question was admitted with a diagnosis of arthritis due to bacteria in the right knee and wrist and was receiving Ceftriaxone intravenously for septic arthritis. The resident's care plan included monitoring the PICC line site for signs of infection but did not specify the need to change the dressing every seven days. During an observation, the dressing was found to be partially detached and not adhering to the skin, increasing the risk of infection and complications. The ADON confirmed the lapse in following the facility's policy for dressing changes.
Failure to Administer Medications Timely for a Resident
Penalty
Summary
The facility failed to ensure timely administration of medications for one resident, identified as R4, which put her at risk of complications. R4, who was moderately cognitively impaired, had diagnoses including rheumatoid arthritis, chronic pain syndrome, and anxiety. She was admitted to the facility and required scheduled pain medication. However, there were multiple instances where her medications were not administered as ordered. Specifically, R4 missed doses of Hydrocodone/acetaminophen, Lidoderm Patch, and Ativan due to issues such as prescription changes, pharmacy delays, and lack of notification to the physician for new prescriptions. Interviews with facility staff, including the Director of Nursing (DON), Infection Preventionist/Assistant Director of Nursing (IP/ADON), and Nurse Practitioner (NP), revealed a breakdown in communication and procedure. The DON acknowledged that narcotic medications required a written prescription to be accessed from the emergency medication kit, and staff were expected to notify the physician of unavailable medications. However, the NP and IP/ADON were not informed of the missed doses, and there was insufficient documentation to confirm notifications were made. The NP expressed that he was unaware of the situation and emphasized that medication should have been available through the emergency kit, indicating a failure in the process to ensure R4 received her necessary medications.
Failure to Document Resident Death and Release Order
Penalty
Summary
The facility failed to document the death of a resident, identified as R115, and did not include a physician order to release the body. This deficiency was identified during a review of the facility's policy on charting and documentation, which requires detailed documentation of a resident's condition, treatments, and events surrounding their death. R115 was admitted with diagnoses including a lumbar fracture, congestive heart failure, and COVID-19. On the day of the incident, a Nursing Progress Note indicated that at 4:00 AM, R115 was experiencing respiratory distress with oxygen saturation below 90%, which stabilized after increasing oxygen flow. Despite these interventions, the resident showed signs of distress, and the family was informed of the condition, opting to avoid hospitalization. There was no further documentation in the Nursing Progress Notes after 4:00 AM regarding R115's condition or subsequent death. Interviews with the Assistant Director of Nursing and the Medical Director revealed that the resident's condition was declining rapidly, and a family meeting was needed. The Medical Director had written a comfort measures order, but hospice care was not initiated before the resident's death. The Medical Director acknowledged the lack of documentation and the absence of an order to release the body to the funeral home, which was a deviation from the facility's policy.
Unauthorized Video Recording of Resident Violates Privacy
Penalty
Summary
The facility failed to maintain a resident's right to personal privacy when a Certified Nurse's Aide (CNA) used a personal cell phone to record two videos of a resident without consent. The first video showed the resident lying in bed, and the second video captured the resident with glasses on upside down. The facility did not provide the requested policy regarding resident rights or video recording of residents, and the CNA admitted to recording the videos without obtaining consent from the resident, the resident's responsible party, or the administrator. The resident involved had severe cognitive impairment and was diagnosed with Alzheimer's Disease, diabetes mellitus, and high blood pressure. The resident's care plan emphasized honoring the resident's preferences, and the admission agreement highlighted the resident's right to refuse being photographed or videotaped. Despite these stipulations, the CNA recorded the videos and shared them with siblings to demonstrate work activities, violating the resident's privacy and dignity. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of clear policies and training regarding resident rights and the use of cell phones for recording. The facility's employee handbook prohibited the use of cell phones during duty and required explicit permission for taking photographs or recordings. However, the CNA was not educated on these policies, leading to the unauthorized recording of the resident, which was deemed undignified and a violation of the resident's right to privacy.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to perform life-saving measures, including CPR, for a resident who was found unresponsive and without a pulse or respirations. The resident was identified as a full code, meaning that life-saving measures should have been initiated immediately. However, the Licensed Practical Nurse (LPN) on duty did not start CPR or instruct the Certified Nursing Assistants (CNAs) to do so, despite being informed multiple times by the CNAs that the resident was a full code. The LPN incorrectly assumed the resident was on hospice and a Do Not Resuscitate (DNR) status, leading to a delay in initiating CPR. The Director of Nursing (DON) was notified by the LPN about the resident's condition and arrived at the scene approximately five to ten minutes later. Upon arrival, the DON confirmed the resident's full code status and instructed the CNAs to begin chest compressions while preparing the crash cart. The DON had to demonstrate the use of the Ambu bag to the LPN, indicating a lack of familiarity with emergency procedures. Emergency Medical Services (EMS) arrived and took over the resuscitation efforts, but the resident was pronounced dead shortly after. Interviews with staff revealed that the LPN was an agency nurse who had not received proper orientation on the facility's emergency procedures, including the location of the crash cart and how to determine a resident's code status. The LPN admitted to having difficulty in the past with identifying residents' code statuses due to discrepancies in the medical records. The facility's failure to ensure that all staff, including agency nurses, were adequately trained and familiar with emergency protocols contributed to the delay in providing life-saving measures to the resident.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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