U-city Forest Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 1301 Partridge Avenue, Saint Louis, Missouri 63130
- CMS Provider Number
- 265736
- Inspections on file
- 31
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at U-city Forest Manor during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
A resident with significant weight loss and multiple medical conditions did not receive dietary supplements as ordered, nor was the supplement increased as recommended by the dietitian. Staff were unaware of the updated recommendations, and the supplements were not provided with meals as required.
A resident on anticoagulant therapy experienced a nose bleed that was not properly assessed or documented across all shifts, and physician orders for saline nasal spray were not followed due to its omission from the MAR and lack of administration documentation. Staff failed to consistently communicate and document the resident's change in condition, and the event was not recognized as requiring a formal assessment, despite ongoing bleeding and the resident's risk factors.
A resident with dysphagia and a history of choking was left unsupervised during lunch, leading to a fatal choking incident. The resident choked on broccoli, which was not part of their meal, indicating it was taken from another plate. The facility failed to follow policies on supervision and dietary modifications, and staff were unaware of the resident's specific needs, contributing to the incident.
A facility failed to update a resident's care plan with speech therapy recommendations for choking prevention. The resident, with severe cognitive impairment and a history of choking, did not have a care plan reflecting necessary strategies for safe swallowing. Despite speech therapy's efforts to educate staff, the care plan lacked updates due to communication failures, leading to continued choking incidents.
The facility did not ensure an RN was present for eight consecutive hours each day, as required, resulting in multiple days without RN coverage. Staff confirmed only one RN was employed full time, and recruitment efforts had not filled the staffing gaps.
The facility failed to obtain and maintain proper Power of Attorney (POA) documentation for two residents, resulting in confusion over decision-making authority. One resident with cognitive impairment was moved to a locked memory care unit after a minor behavioral incident, without assessment, alternative interventions, or required notifications to the physician or family. Documentation and communication failures were identified, including inconsistent records regarding POA status and lack of proper notification for significant changes.
A resident who was dependent for ADLs, cognitively impaired, and always incontinent was left in a urine-soaked brief without timely perineal care. Multiple CNAs removed the soiled brief but failed to clean the resident or apply a clean brief as required by facility policy. Staff interviews confirmed awareness of the need for perineal care after incontinence, but the care was not provided, leaving the resident feeling unclean and uncared for.
A cockroach was observed crawling on a resident's blanket while the resident, who was cognitively impaired and dependent for care, was in bed. Despite regular pest control treatments targeting German roaches throughout the facility, staff interviews confirmed an ongoing cockroach problem. The incident demonstrated that the pest control program was not effective in preventing pest presence in resident areas.
The facility did not follow their policy of retaining grievance logs for three years, as only logs from January 2024 to the current date were available. The ADON confirmed the change in the logging process and the inability to locate previous logs. The administrative team expected compliance with the three-year retention policy.
Facility staff failed to provide 24-hour protective oversight for two residents with a history of elopements and wandering, as well as failed to ensure smoking assessments were completed for two residents who smoked. Staff did not follow physician's orders to monitor wanderguard devices, and there was confusion about who was responsible for smoking assessments.
The facility failed to provide eight hours of RN coverage for 16 out of 92 days, potentially causing unmet health needs for all residents. Despite the facility's staffing policy requiring adequate RN and nursing staff, the Payroll Based Journal (PBJ) Staffing Data Report showed no RN coverage on 16 specific dates. Interviews with administrative staff confirmed this deficiency.
The facility failed to ensure proper labeling and storage of medications, with issues found in three out of four medication carts and one medication room. Insulin pens were opened and dated beyond 28 days, and multiple OTC medications were undated and expired. Staff interviews confirmed that medications should be dated upon opening and expired medications should not be administered, but these practices were not consistently followed.
The facility failed to ensure accurate and updated code statuses for three residents. One resident had conflicting information in their records, another had an outdated full code status despite being rarely understood, and a third resident's code status had not been updated for over a year. The Social Worker was responsible for these updates but had not performed them in a timely manner.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents. The Regional Business Office Manager indicated that SNFABN forms were provided for Medicare Part B discharges, not Medicare Part A, which was confirmed by the Administrator, DON, ADON, and Regional Operational Director.
The facility failed to ensure that residents with mental disorders had a DA-124 Level I screen (PASARR) as required. Three residents with significant cognitive impairments and psychiatric diagnoses had no PASARR Level I on file, and the facility's administration confirmed that these screenings should have been completed within 30 days of admission.
The facility failed to complete a discharge summary for a resident with high blood pressure, depression, and stroke. The resident was discharged in stable condition with necessary medications and documentation, but no discharge summary was included in the medical record. The Regional Clinical Director confirmed this oversight.
The facility failed to provide adequate ADL care for two residents who were dependent on staff for personal care. Both residents were observed with excessively long and dirty fingernails, despite expressing a need for grooming. Staff interviews revealed confusion about responsibilities for nail care, particularly for diabetic residents, leading to a lack of proper grooming.
The facility failed to ensure a resident receiving routine dialysis had accurate physician's orders, consistent communication, and a dialysis contract. The resident's care plan required monitoring of vital signs, weight, and the AVF site, but these were not documented. Staff interviews revealed that dialysis communication forms were often lost and not completed, and the facility lacked a dialysis contract with the provider.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.41% error rate. An LPN did not follow proper procedures for insulin pen use, including wiping the rubber seal with alcohol and priming the pen, for two residents with diabetes. The facility lacked a policy on insulin pen priming, contributing to the errors.
The facility failed to follow infection control standards by not properly disinfecting glucometers between uses and not adhering to proper hand hygiene and glove use during wound care for two residents. Staff used alcohol pads instead of EPA-registered disinfecting wipes for glucometers and double-gloved during wound care, contrary to facility policy.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Failure to Provide and Increase Dietary Supplements as Ordered
Penalty
Summary
The facility failed to provide a dietary supplement as ordered and did not implement the dietitian's recommendation to increase the supplement for a resident experiencing weight loss. The resident, who had diagnoses including cerebral palsy, severe cognitive impairment, and severe protein-calorie malnutrition, was on a regular pureed diet with nectar thickened liquids and was supposed to receive a house shake twice daily and Majic Cup with lunch and dinner. The dietitian recommended increasing the house shake to three times daily with meals due to ongoing weight loss, but this recommendation was not implemented. Documentation showed the resident continued to receive the supplement only twice daily, and there was no evidence of the increased frequency being provided. Observation during a meal revealed the resident did not receive the required supplements with lunch, and staff were unaware of the missed supplements and the dietitian's updated recommendation. The process for communicating dietary changes involved verbal and email notifications from the dietitian to the ADON, who was then responsible for ensuring nurses updated orders and dietary slips. However, this process was not followed, resulting in the resident not receiving supplements as ordered or as recommended by the dietitian.
Failure to Assess, Document, and Follow Physician Orders After Resident Nose Bleed
Penalty
Summary
The facility failed to properly assess and document a resident's change in condition following a nose bleed, and did not ensure physician orders were followed regarding the administration of saline nasal spray. The resident, who had diagnoses including hypertension, diabetes, major depressive disorder, and was on anticoagulant medications for a history of stroke, experienced a nose bleed that was initially addressed by an LPN with non-pharmacological interventions. The physician was notified and subsequently ordered to hold the resident's anticoagulant medications and to administer saline nasal spray three times daily. However, the saline nasal spray was not added to the Medication Administration Record (MAR), and there was no documentation that it was administered as ordered. Documentation gaps were evident across shifts. There were no nursing notes during the overnight shift following the initial nose bleed, despite evidence of continued bleeding observed the next morning. The overnight LPN did not document any care or observations in the resident's chart, and the CNA on duty was not given specific instructions regarding the resident's care. The following morning, another LPN found the resident with blood on the face and bedding, and the resident reported ongoing nose bleeds. The resident was subsequently sent to the hospital for evaluation and treatment after further assessment revealed lethargy and abnormal vital signs. Interviews with staff revealed inconsistent communication and follow-through regarding the resident's change in condition. The LPN who initially responded to the nose bleed did not complete a formal change in condition assessment. The overnight LPN and CNA did not witness active bleeding but observed evidence of it and did not document or escalate the situation. The Assistant Director of Nursing and Administrator stated they did not consider a nose bleed a change in condition, despite the resident's risk factors and care plan instructions to monitor for bleeding. The lack of documentation, assessment, and timely administration of ordered treatments contributed to the deficiency.
Inadequate Supervision Leads to Resident Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a diagnosis of dysphagia and a history of choking. The resident was left unsupervised during lunch in the dining room, which led to a choking incident. Despite staff intervention, they were unable to clear the resident's airway, and the resident eventually expired after emergency medical staff dislodged a large piece of broccoli from the resident's throat. The broccoli was not part of the resident's lunch tray, indicating that the resident may have taken it from another resident's plate. The facility's policies on safety and supervision of residents, as well as the interdepartmental notification of diet changes, were not adequately followed. The resident's care plan did not address previous choking incidents or the speech therapist's discharge recommendations for close supervision and specific dietary modifications. Staff interviews revealed a lack of awareness and implementation of these recommendations, contributing to the resident's unsupervised state during meals. The resident had a history of severe cognitive impairment, anxiety disorder, aphasia, and stroke, which increased the risk of choking. Despite these known risks, the facility did not ensure that staff were within arm's reach of the resident during meals, as recommended by the speech therapist. The failure to provide appropriate supervision and adhere to dietary restrictions directly led to the resident's choking incident and subsequent death.
Failure to Update Care Plan with Speech Therapy Recommendations
Penalty
Summary
The facility failed to ensure that a resident's care plan reflected current needs, specifically regarding speech therapy recommended choking strategies. The resident, who had a history of choking, was not provided with a care plan that included the necessary strategies to prevent further incidents. The resident had severe cognitive impairment and was on a mechanical soft diet with thin liquids, but continued to experience choking episodes, including one incident involving a breadstick. The resident's care plan did not incorporate the speech therapy discharge recommendations, which included close supervision and specific strategies to facilitate safe swallowing. Despite the speech therapist's efforts to educate staff and provide cues to the resident during meals, the care plan was not updated to reflect these necessary interventions. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan requirements, including the need for close supervision and monitoring for signs of dysphagia. The MDS Coordinator, responsible for updating care plans, was unaware of the speech therapy recommendations due to a lack of communication from the speech therapy department. This oversight resulted in the resident's care plan not being updated to include critical strategies for preventing choking incidents. The Assistant Administrator and Assistant Director of Nursing acknowledged the deficiency and expressed that the speech therapy recommendations should have been included in the care plan.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days a week, as required. Review of daily assignment sheets revealed that there was no RN present in the facility on eight specific days within a fifteen-day period, despite a census of 75 residents. Interviews with the Assistant Director of Nursing (ADON) and the Assistant Administrator (AA) confirmed awareness of the requirement and acknowledged that only one RN was employed full time, resulting in gaps in RN coverage. The facility had been actively recruiting for additional RNs but had not been successful in filling the positions, leading to the deficiency.
Failure to Obtain Proper POA Documentation and Involuntary Seclusion Without Assessment
Penalty
Summary
The facility failed to uphold residents' rights to dignity, self-determination, and communication by not obtaining or maintaining proper Power of Attorney (POA) documentation for two residents. In one case, a former facility employee was listed as a resident's POA for nearly two years without the appropriate, legally valid forms, as the documentation was incomplete and not notarized. When the error was discovered, the resident's family attempted to submit new POA paperwork, but it was also found to be incomplete, resulting in the resident being considered responsible for their own decisions despite documented cognitive impairment and a diagnosis of dementia. Staff interviews confirmed that the facility acted as if the former employee was the POA without proper verification, and there was confusion and lack of clarity among staff regarding the resident's decision-making status. Additionally, the facility failed to respect a resident's right to be free from involuntary seclusion. The resident, who had moderate cognitive impairment and a history of dementia, was moved to a locked memory care unit after being observed peeling wallpaper in the facility's entryway. Staff interviews and documentation revealed that the resident was easily redirected, not a threat to themselves or others, and did not display aggressive or combative behavior. The decision to move the resident to a more restrictive environment was made without prior assessment, alternative interventions, or notification to the resident's physician, psychiatrist, or family. There was also a lack of documentation in the resident's electronic medical record regarding the incident, the rationale for the room change, and the notifications that should have occurred. For another resident with severe cognitive impairment and a diagnosis of dementia, there was inconsistency in the facility's records regarding the existence of a POA. While the care plan and face sheet indicated that the resident's family member was the POA, a faxed document from the ADON stated otherwise. Staff interviews highlighted a lack of consistent procedures for verifying, documenting, and communicating POA status, as well as failures to notify the appropriate parties of significant changes or incidents as required by facility policy.
Failure to Provide Timely and Appropriate Perineal Care After Incontinence Episode
Penalty
Summary
Facility staff failed to provide timely and appropriate perineal care to a dependent resident following an incontinence episode. The resident, who was cognitively impaired, dependent for toileting and transfers, always incontinent of bladder and bowel, and at risk for pressure ulcers, was observed lying in bed with a urine-soaked brief. Staff did not attend to the resident's incontinence needs that morning, as confirmed by the resident during an interview. During observations, two CNAs removed the urine-soaked brief but did not perform perineal care or apply a clean brief before leaving the resident covered with a blanket. Later, two other CNAs entered the room, placed a clean brief on the resident, and dressed and transferred the resident without performing perineal care. Interviews with the CNAs revealed that they were aware of the expectation to provide perineal care after incontinence episodes but failed to do so, with some staff assuming the care had already been provided by others. The resident reported feeling unclean and uncared for when perineal care was not performed after incontinence episodes and stated this occurred often. Facility policy required staff to provide incontinence care and barrier cream after each episode, and staff interviews confirmed knowledge of these expectations. The failure to provide perineal care was acknowledged by staff and administration as not meeting the resident's needs and not respecting the resident's dignity.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of a cockroach crawling on a resident's blanket while the resident was lying in bed. The resident involved was cognitively impaired, had impairment on both sides of the lower body, was dependent for toileting and transfers, and was always incontinent of bladder and bowel. Diagnoses included diabetes mellitus, stroke, and dementia. The pest control company's service report indicated ongoing efforts to address a German roach infestation, including treatments in the kitchen, therapy room, and resident rooms. Despite these measures, a cockroach was observed on the resident's blanket, and staff confirmed the ongoing presence of cockroaches in the facility. Interviews with staff revealed that cockroaches had been a persistent issue in the building, with monthly pest control treatments failing to fully eliminate the problem. The Housekeeping Supervisor confirmed the incident and acknowledged the ongoing problem, suggesting that recent treatments in other areas may have displaced cockroaches to new locations within the facility. The Assistant Administrator stated that staff and residents were expected to report sightings, but acknowledged that cockroaches had been reported earlier in the month. The deficiency had the potential to affect all residents in the facility.
Failure to Retain Grievance Logs for Required Period
Penalty
Summary
The facility failed to follow their policy by not retaining three years of grievance logs. During a review, it was found that the grievance binder only contained logs from January 2024 to the current date, with no logs available for 2022 or 2023. The Assistant Director of Nursing (ADON) confirmed that the facility had recently changed the process of logging grievances and was unable to locate any other grievance binders. The Administrator, Director of Nursing, ADON, and Regional Operational Director all stated that they expected the facility to retain grievance logs for three years, as per their policy.
Failure to Monitor Wanderguards and Conduct Smoking Assessments
Penalty
Summary
Facility staff failed to provide 24-hour protective oversight for two residents with a history of elopements and wandering. The residents resided on a secured behavior unit, and staff did not follow physician's orders to monitor the residents' wanderguard devices as ordered. Specifically, Resident #42 was discovered not wearing their wanderguard, and Resident #53's wanderguard was found to be non-functional. The facility's Elopement Policy and Procedure required that each wanderguard be checked for functionality every shift and documented on the Treatment Administration Record (TAR), but this was not done. Additionally, staff were unaware of how to check the functionality of the wanderguards, and the necessary handheld testing device was not readily available or used correctly. This lack of oversight and adherence to policy resulted in the residents being at risk of elopement without proper monitoring. The facility also failed to ensure that smoking assessments were completed for two residents who smoked. Resident #41 and Resident #39 both had care plans indicating they chose to smoke cigarettes and required monitoring during smoking times for safety. However, there were no smoking assessments documented in their medical records. Interviews with staff revealed confusion about who was responsible for completing these assessments, with the Social Worker admitting that she had not completed any smoking assessments during her tenure. This oversight left the residents at risk of smoking-related injuries without proper evaluation and monitoring. During interviews, the Assistant Director of Nurses (ADON) and other staff members acknowledged the deficiencies. The ADON was unaware of the missing or non-functional wanderguards until informed by state surveyors. The ADON also found the wanderguard testing device in its original box, indicating it had not been used. The facility's Administrator, ADON, and Director of Nursing confirmed that wanderguards should be monitored and documented as ordered, and smoking assessments should be completed annually and as needed. These failures in following established protocols and ensuring staff competency in using safety devices and conducting assessments led to significant lapses in resident safety and care.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight hours of Registered Nurse (RN) coverage for 16 out of 92 days, which had the potential to cause unmet health needs for all residents. The facility's staffing policy, dated July 2019, stated that adequate staffing would be maintained to meet residents' needs, including having licensed RN and nursing staff available to provide and monitor care. However, a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for the first fiscal quarter of 2023 showed that there was no RN coverage on 16 specific dates. Interviews with the Assistant Director of Nursing (ADON) and other administrative staff confirmed the lack of RN coverage on these dates, despite the expectation that the facility would have eight hours of RN coverage daily.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an inspection, it was found that three out of four medication carts and one medication room had issues. Specifically, insulin pens were opened and dated more than 28 days, and multiple bottles of over-the-counter (OTC) medications were undated and expired. The facility's Medication Storage Policy mandates that medications and biologicals be stored safely and securely, and that outdated or deteriorated drugs be immediately withdrawn from stock and disposed of properly. However, observations revealed that this policy was not followed, as evidenced by the presence of expired and undated medications in the medication carts and room checked during the survey. The census at the time was 73 residents. During interviews, a Certified Medical Assistant (CMT) acknowledged that medications should be dated upon opening and that expired medications should not be administered to residents. A Licensed Practical Nurse (LPN) instructed the CMT to discard expired medications. The Director of Nursing (DON) confirmed that staff were expected to date OTC medications upon opening and that insulin pens should only be used for 28 days. The DON also stated that staff should check expiration dates before administering medications and properly dispose of expired medications. Despite these expectations, the survey revealed significant lapses in adherence to the facility's medication storage policy, leading to the identified deficiencies.
Failure to Ensure Accurate and Updated Code Statuses
Penalty
Summary
The facility failed to ensure that code statuses were accurate, signed, and updated in the medical records for three residents. Resident #52 had conflicting information in their records, with a care plan indicating a full code status while the resident expressed a desire to be a Do Not Resuscitate (DNR). The Licensed Practical Nurse (LPN) confirmed the confusion, noting that both the electronic medical record (EMR) and paper chart contained conflicting code statuses. The Social Worker was identified as responsible for updating code statuses but had not done so in a timely manner. Resident #48's code status was also outdated, with records showing a full code status that had not been updated for over a year. The resident was rarely or never understood and had no speech, making it crucial for the responsible party to update the code status. Similarly, Resident #19's code status was outdated, with records showing a full code status that had not been updated for over a year. The Social Worker initially thought the Nursing Manager was responsible for updating code statuses but later clarified that it was her responsibility. The Administrator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that the Social Worker was responsible for ensuring code statuses were clear, accurate, and updated yearly or as needed.
Failure to Provide SNFABN for Medicare Part A Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents who remained in the facility upon discharge from Medicare Part A services. Specifically, Resident #44 had Medicare Part A skilled services from 11/1/23 to 11/17/23, and Resident #34 had Medicare Part A skilled services from 4/3/24 to 4/25/24. In both cases, no SNFABN form was issued to inform the residents of their potential liability for payment for non-covered services. During interviews, the Regional Business Office Manager indicated that the facility provided SNFABN forms when residents were discharged from Medicare Part B, not Medicare Part A. Additionally, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Regional Operational Director confirmed that they would expect the SNFABN to be completed after a resident's discharge from Medicare Part A. This oversight led to the deficiency noted in the report.
Failure to Ensure PASARR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that residents with mental disorders had a DA-124 Level I screen (PASARR) as required. This deficiency was identified for three residents who had diagnoses including seizures disorder, depression, dementia, schizophrenia, and bipolar disorder. For Resident #8, admitted on 9/18/20, the medical record showed no PASARR Level I on file despite the resident having moderate cognitive impairment and multiple psychiatric diagnoses. The Corporate Nurse mentioned that the old computer system used by previous owners might have contained the PASARR, but the current facility did not have access to it. Similarly, Resident #41, admitted on 4/1/22, and Resident #3, admitted on 3/6/2013, also had no PASARR Level I on file despite having significant cognitive impairments and psychiatric diagnoses. Interviews with Social Services and the facility's administration confirmed that PASARRs should have been completed within 30 days of admission, but they were unable to locate the necessary documentation for these residents.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. The resident, who had diagnoses of high blood pressure, depression, and stroke, was admitted on an unspecified date and discharged on another unspecified date. Progress notes indicated that the resident was scheduled for discharge and left the facility in stable condition with necessary medications and documentation. However, a review of the medical record showed no discharge summary was completed. During an interview, the Regional Clinical Director confirmed that the discharge summaries were not done and should have been completed prior to the resident's discharge.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents who were dependent on staff for personal care. Resident #27, who is cognitively impaired and dependent on staff for all ADLs except eating, was observed over several days with extremely long and dirty fingernails. Despite the resident expressing a desire to have their nails cut, staff interviews revealed that CNAs were unsure about their responsibilities regarding nail care for diabetic residents, leading to a lack of proper grooming for Resident #27. The care plan for this resident included goals for restorative therapy and collaboration between nursing and restorative staff, but these were not effectively implemented to address the resident's grooming needs. Similarly, Resident #67, who is cognitively impaired and at risk for poor hygiene due to dementia, was also observed with excessively long fingernails. The resident expressed a need for nail trimming, but staff interviews indicated confusion about who was responsible for this task. The care plan for Resident #67 included specific instructions for maintaining hygiene, including nail care, but these were not followed. Interviews with various staff members, including CNAs, an LPN, and the Assistant Director of Nursing, highlighted a lack of clarity and communication regarding the responsibility for nail care, ultimately leading to the deficiency in ADL care for these residents.
Failure to Ensure Accurate Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident receiving routine dialysis had accurate physician's orders, consistent communication, and a dialysis contract with the dialysis provider. The resident, who was cognitively impaired and diagnosed with heart failure, end-stage renal disease (ESRD), and dementia, had no dialysis contract, no recent dialysis communication forms, and no monitoring of the arteriovenous fistula (AVF) dialysis site documented in their medical record. The resident's care plan indicated the need for monitoring vital signs, weight, and the AVF site, but these were not reflected in the Treatment Administration Record (TAR) or physician's orders for several months. Interviews with facility staff, including an LPN, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, revealed that the dialysis communication forms were often lost and not completed as required. The ADON confirmed that the resident's weight and vitals should have been documented each time the resident attended dialysis, and the dialysis site should have been checked every shift. The facility also lacked a dialysis contract with the provider, and there were discrepancies in the physician's orders regarding the resident's dialysis schedule and site monitoring.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 7.41% error rate. This was observed during the administration of insulin to two residents. For Resident #44, the LPN did not wipe the insulin pen's rubber seal with alcohol and did not prime the insulin pen before administering 20 units of Novolog insulin. Similarly, for Resident #20, the LPN did not wipe the insulin pen's rubber seal with alcohol and did not prime the insulin pen before administering 9 units of Humalog insulin. Both residents have significant medical histories, including diabetes, which necessitates precise insulin administration to manage their conditions effectively. During interviews, it was revealed that the LPN was unaware of the priming steps required for insulin pens, and the Director of Nursing (DON) was unsure about the necessity of pen priming before insulin administration. The facility did not have a policy for insulin pen priming and relied on the manufacturer's instructions, which were not followed in these instances. The DON and other staff members acknowledged the expectation for staff to be free of medication errors but did not have a clear understanding or policy in place to ensure compliance with proper insulin administration procedures. The lack of adherence to the manufacturer's instructions for insulin pen use and the absence of a facility policy on insulin pen priming contributed to the medication errors observed. The facility's leadership, including the Administrator, DON, Assistant Director of Nursing, and Regional Operational Director, recognized the expectation for error-free medication administration but did not have adequate measures in place to prevent these errors, leading to the identified deficiency.
Infection Control Deficiencies in Glucometer Cleaning and Wound Care
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control when it did not clean shared medical equipment between resident use with an approved Environmental Protection Agency (EPA)-registered disinfectant. Specifically, the facility did not properly disinfect glucometers between uses for two residents. Licensed Practical Nurse (LPN) G used alcohol pads instead of the required EPA-registered disinfecting wipes to clean the glucometer between uses for two residents. This practice was observed and confirmed through interviews with other staff members, who indicated that the correct procedure involved using bleach wipes or Sani wipes, not alcohol pads. The Director of Nursing (DON) and other staff members confirmed that the facility's policy required the use of Clorox wipes for disinfecting glucometers, and alcohol pads were not acceptable for this purpose. Additionally, the facility failed to ensure proper hand hygiene and glove use during wound care for two residents. LPN E did not follow the correct procedure for changing gloves and performing hand hygiene while providing wound care. The LPN was observed double-gloving and not removing all gloves before performing hand hygiene, which is against the facility's infection control standards. Interviews with other staff members, including Certified Medication Technician (CMT) F, LPN G, and the Assistant Director of Nursing (ADON), confirmed that double-gloving is not an acceptable practice and that all gloves should be removed, and hand hygiene should be performed between dirty and clean tasks. The deficiencies were observed during wound care for two residents with severe cognitive impairments and multiple diagnoses, including Alzheimer's disease, dementia, and high blood pressure. The facility's failure to adhere to proper infection control practices was confirmed through multiple observations and interviews with staff members, including the Nurse Practitioner (NP), Registered Nurse (RN) B, and the Regional Operational Director. The facility's leadership, including the Administrator, DON, ADON, and Regional Operational Director, acknowledged that staff were expected to follow acceptable infection control standards of practice.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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