Villa At Blue Ridge, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Missouri.
- Location
- 701 Blue Ridge Road, Columbia, Missouri 65201
- CMS Provider Number
- 265251
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Villa At Blue Ridge, The during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, dementia, psychotic disturbance, and anxiety was verbally abused by a CNA who entered the room at night and repeatedly yelled, mocked, and demeaned the resident instead of using calm, supportive communication as outlined in the care plan. Video footage captured the CNA loudly confronting the resident about their actions, denying the resident's delusional perceptions, stating the resident had "no freaking clue" what they were doing or where they were, and ultimately yelling at the resident to go to sleep and slamming the door. The administrator, DON, law enforcement, and the resident's responsible party later agreed that the CNA's conduct on the video constituted verbal abuse.
Staff failed to follow facility policy for post-fall assessment and documentation after an unwitnessed fall involving a resident with moderate cognitive impairment and a history of prior falls. Video showed the resident on a fall mat beside the bed, and a CNA reported this twice to an LPN. The LPN delayed going to the room, did not complete a Report of Event Form, and only obtained vital signs more than an hour later without performing or documenting required neuro checks or range-of-motion assessments. The resident’s responsible party reported assisting the resident back to bed and remaining in the room for an extended period without any staff entering to assess the resident, and leadership confirmed that the expected post-fall procedures and documentation were not carried out.
Staff did not consistently follow facility policies requiring dual narcotic counts and timely medication ordering, resulting in missing documentation of controlled substance counts across multiple shifts and unavailability of ordered medications for three sampled residents. Narcotics were not always counted and signed by two staff at shift changes, and some shifts had no signatures at all. Additionally, medications were not reordered in advance as required, leading to situations where residents’ prescribed medications were not on hand and therefore not administered as ordered.
Staff failed to notify physicians when ordered medications were unavailable for three residents, despite facility policy requiring nursing to contact the prescriber if medication delivery is delayed or a drug is not available. One moderately cognitively impaired resident missed doses of antihypertensive and constipation medications, another cognitively intact resident missed multiple doses of supplements and other prescribed drugs, and a severely cognitively impaired resident missed repeated doses of medications for hyperlipidemia, dementia, anticoagulation, hypokalemia, cystitis, and vitamin deficiency. MARs showed numerous entries of medications marked as not available, while nurse notes lacked documentation of physician or pharmacy notification, and interviews with a CMT, the ADON, and the DON confirmed that nurses were expected, but failed, to contact the physician and pharmacy in these situations.
Staff failed to safeguard a cognitively intact resident’s $1700 in cash and did not promptly investigate repeated reports that the money was missing. At admission, an RN accompanied the resident to the business office, where the resident handed $1700 in cash to a staff member to be placed in an account, but no corresponding deposit was ever recorded. Over the following months, the resident and family repeatedly reported the missing funds to multiple staff, including social services and the Activity Director, who in turn informed the administrator. The administrator did not initiate an investigation or notify the state agency at that time, despite facility policy requiring thorough investigation and reporting of alleged misappropriation. Only after the Director of Operations was informed of the ongoing concern was an investigation started, confirming that the resident had given $1700 to a staff member and that the funds were never deposited.
Staff failed to ensure timely reporting of an allegation of misappropriation of a resident’s narcotic medication to the state agency. A resident with moderate cognitive impairment and PRN opioid orders had a bottle of liquid morphine that an LPN discovered with a broken seal and clear liquid instead of the expected pink solution, suggesting possible tampering or dilution. The LPN reported this to the ADON, who in turn informed the administrator. The pharmacist confirmed the medication should remain pink and that water would dilute the color. Although leadership acknowledged that the administrator was responsible for reporting such misappropriation allegations to the state within 24 hours, neither the administrator nor the ADON could confirm that the required report was made.
Staff failed to conduct and document a thorough investigation into an allegation that a resident’s PRN liquid morphine, ordered as an opioid pain medication, had been tampered with. An LPN discovered during a narcotic count that the morphine bottle’s seal was broken and the liquid appeared clear instead of pink, despite the medication reportedly never having been used since receipt. The LPN reported this to the ADON, and a pharmacist later confirmed that the solution should remain pink and that dilution with water would change the color. Although administration reported that an investigation was completed and the allegation unsubstantiated, there was no documentation in the resident’s record or facility files to show that a required, thorough investigation of the alleged misappropriation was performed.
Staff did not notify the physician or family after changes in condition for three residents, including falls and significant weight loss. Documentation was lacking for required notifications, and family members expressed concerns about communication. Staff interviews confirmed the expectation to notify, but no policy was provided.
Staff did not consistently update or revise care plans after significant changes in residents' conditions, such as falls or notable weight loss, and failed to perform required quarterly care plan reviews. For example, a resident's care plan was not updated after a fall that led to an ER visit, and another resident's care plan lacked timely interventions for significant weight loss. The DON and administrator confirmed that care plans should be updated after such events and on a regular schedule, but acknowledged these updates were not completed as required.
Facility staff failed to follow required hiring protocols by employing a CNA with a Class A Felony conviction for First Degree Assault, a disqualifying offense. The initial background check did not identify the conviction because the mandated Family Safe Care Registry was not used, and the issue was only discovered during a later review.
Staff did not provide written bed hold policy notifications to three residents or their representatives during hospital transfers, as required by facility policy. Record reviews and resident interviews confirmed the absence of these notices, and staff interviews revealed a lack of oversight to ensure the notifications were consistently issued and documented.
Staff failed to ensure a resident received pain medications as ordered after a surgery was postponed, with missed doses due to lack of physician orders and poor communication about medication holds. Additionally, two residents who smoke were not re-assessed for smoking privileges after incidents, and staff were unclear about responsibility for completing smoking assessments.
Staff failed to enforce facility policies prohibiting residents from retaining smoking materials, resulting in two residents keeping cigarettes and lighters in their possession. One resident, assessed as cognitively intact, was observed smoking in a prohibited area and had no smoking interventions on the care plan. Another resident, whose care plan required supervised smoking and storage of smoking materials at the nurses' station, was found with cigarettes and a lighter in a public area. Staff interviews revealed confusion about which residents were allowed to keep smoking supplies, leading to inadequate supervision and increased accident risk.
Facility staff failed to complete quarterly MDS assessments for 19 residents within the required 92-day interval, as mandated by federal regulations. This deficiency was due to the previous MDS Coordinator's frequent absences, resulting in a backlog. The current MDS Coordinator is working to catch up, but the DON has been unavailable to assist due to other responsibilities. The administrator was unaware of the backlog, and corporate oversight had not reported the issue.
The facility failed to implement a comprehensive water management program, lacking policies, control measures, and testing protocols to prevent Legionella growth. Staff interviews revealed a lack of awareness and understanding of the program, contributing to a resident testing positive for Legionella after being hospitalized with respiratory distress.
The facility failed to conduct required CNA registry checks on five employees, including a Dietary Aide and a Registered Nurse, due to a lack of awareness by the assistant business office manager. Additionally, the facility did not investigate an injury of unknown origin for a resident with intact cognition and physical impairments, who was found with facial and wrist injuries. The ADON did not conduct a formal investigation or report the incident, and the Administrator was not informed, indicating a breakdown in communication and procedure adherence.
Facility staff failed to provide prescribed treatment for a resident with cognitive impairment and medical conditions, as Tubi grips were not consistently applied as ordered. Additionally, there were inconsistencies in code status documentation for two residents, with conflicting records of full code and DNR status. Staff interviews revealed a lack of awareness and understanding of the documentation discrepancies, and audits were not conducted frequently enough to ensure accuracy.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, as required. The RN staff schedule showed multiple days without adequate coverage in July, August, September, and early October 2024. Interviews revealed that the facility had only one full-time RN, the DON, who worked night shifts and was on call. The ADON and administrator acknowledged the staffing shortfall and the requirement for RN coverage.
Facility staff failed to follow immunization policies for pneumococcal vaccines, resulting in two residents not being offered or documented as receiving the vaccines. The Infection Preventionist admitted to not maintaining the vaccination program, and the administrator acknowledged the oversight.
Facility staff did not complete a comprehensive discharge summary or post-discharge plan for a resident, as required by policy. The SSD, responsible for this task, admitted to not completing the necessary documentation. The ADON and administrator confirmed the SSD's role in ensuring discharge information is documented.
Facility staff failed to provide appropriate dialysis care for a resident, lacking necessary documentation and assessments as per professional standards. The resident's medical records did not include vital signs, shunt monitoring, or communication forms. Interviews revealed staff were unaware of the dialysis care policy, and there was a lack of oversight and education on proper procedures.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.45% error rate. A CMT crushed Metoprolol Succinate ER tablets, which should not be crushed, and administered Latanoprost eye drops to both eyes of a resident, contrary to the order for the left eye only. The errors were acknowledged by the CMT, and the importance of following medication orders was emphasized by the ADON and Charge Nurse.
Facility staff failed to document collaboration with hospice providers for two residents receiving hospice services. Despite expectations for regular communication and care plan documentation, records for a resident with cancer and another with kidney disease lacked necessary documentation. Interviews with staff, including an LPN, ADON, and the administrator, confirmed the expectation for documentation, which was not met.
Facility staff failed to secure medication and treatment carts, leaving them unlocked and unattended in public areas accessible to residents. Despite the facility's policy requiring carts to be locked, observations showed repeated instances of unsecured carts. Interviews with staff confirmed the carts should be locked unless directly attended, acknowledging the risk of resident access or drug misplacement.
Facility staff failed to document a physician-ordered wound care treatment for a resident, as required by professional standards. The resident's medical records did not include the physician's order for wound care, despite the resident being cognitively intact and having a specific treatment regimen prescribed. Interviews with staff revealed that both nurses and the DON were responsible for inputting and verifying orders, but the LPN was unaware of the wound care order. The administrator confirmed the expectation for accurate order entry and acknowledged the risk of infection if orders were not followed.
Facility staff failed to update care plans for three residents after falls, as required by policy. A resident with moderate cognitive impairment, another with severe cognitive impairment, and a cognitively intact resident all experienced falls, but their care plans lacked new interventions. Interviews revealed confusion about responsibility for updating and auditing care plans, with the MDS Coordinator admitting to missing updates due to health issues.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse when a CNA entered the resident's room during the night and repeatedly yelled at and mocked the resident. Video footage from the resident's room showed the CNA loudly confronting the resident about "leaving stuff alone" and questioning what the resident was doing. When the resident, who was experiencing delusional thinking about killing an animal, attempted to explain, the CNA loudly denied the resident's perceptions, repeatedly told the resident to leave things alone, and stated the resident had "no freaking clue" what they were doing or where they were. The CNA continued to argue with the resident, raised their voice, and ultimately yelled at the resident to go to sleep before slamming the door as they exited the room. The resident had a documented history of moderate cognitive impairment with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance with hallucinations and delusions, and anxiety. The resident's care plan directed staff to calm the resident during distress related to decision making by talking slower and calmer, giving time to make decisions, and offering supportive measures such as contacting family. Instead of following these approaches, the CNA engaged in mocking and ridiculing behavior, used demeaning language, and failed to use calm communication techniques appropriate for a resident with dementia and psychotic symptoms. The administrator, DON, police officer, and the resident's responsible party all later characterized the CNA's behavior, as seen on the video, as verbal abuse toward the resident.
Failure to Complete and Document Required Post-Fall Assessment
Penalty
Summary
Facility staff failed to meet professional standards of care by not completing and documenting a fall assessment as required by facility policy after an unwitnessed fall involving one resident. The facility’s Event Investigation policy directed staff to complete a Report of Event Form as soon as possible for unexpected events such as falls, and to document the event location and type, vital signs, mental/neurological status, range of motion, and pain assessment. The resident’s admission MDS showed moderate cognitive impairment and a history of two or more non-injury falls since admission. Video footage from the resident’s room showed a CNA entering the room twice with the resident’s lower body on the fall mat/mattress next to the bed. The CNA reported to the nurse on two occasions that the resident was on the fall mat/mattress. The EMR for the date of the incident did not contain documentation that the LPN completed a Report of Event Form or performed and documented the required post-fall assessments, including neurological status and range of motion. The LPN stated that the CNA reported the unwitnessed fall but the LPN was busy and did not immediately assess the resident, and that approximately 10 minutes later the resident’s family arrived and assisted the resident back to bed. The LPN did not enter the room until after the family left over an hour later, at which time the resident was asleep; the LPN obtained vital signs but did not initiate neurological or range of motion checks and only believed a progress note had been documented. The administrator and DON both stated they expected completion of an event form, vital signs, neurological checks, range of motion, pain assessment, and documentation per policy for an unwitnessed fall. The resident’s responsible party reported arriving, assisting the resident from the fall mat/mattress to bed, remaining for about an hour and a half, and not seeing any staff enter the room or assess the resident during that time.
Failure to Perform Dual Narcotic Counts and Ensure Medication Availability
Penalty
Summary
Facility staff failed to follow professional standards and facility policy for controlled substance management and medication administration. Review of the facility’s policies showed narcotics were to be physically counted at each shift change by both the incoming and outgoing licensed nurse or CMT, with both staff signing the Shift Verification of Controlled Substance Count form. From 12/08/25 through 12/31/25, multiple shifts lacked the required two staff signatures, and on some shifts there were no signatures at all, indicating that the required dual narcotic counts were not consistently completed or documented. Interviews with an LPN, the administrator, the ADON, and the DON confirmed that staff were required to perform and document narcotic counts at the beginning and end of each shift, and that the DON/ADON were responsible for auditing these forms. They also stated that failure to complete these counts could result in an inability to determine why a narcotic count was incorrect or who might be responsible for missing medication. The facility’s Medication Ordering and Receiving from Pharmacy policy required staff to reorder medications four days in advance of need, and at least seven days in advance for medications requiring special processing, to ensure an adequate supply. The Medication Administration Guidelines policy required that residents receive medications on a timely basis and in accordance with established policies. Despite these policies, surveyors determined that medications were not available as ordered for three sampled residents, and medications were not administered as ordered when unavailable. The report identifies that these failures occurred for three residents out of three sampled, in the context of a facility census of 90.1, but does not provide additional clinical details about the residents’ diagnoses or conditions at the time of the deficiency.
Failure to Notify Physicians When Ordered Medications Were Unavailable
Penalty
Summary
Facility staff failed to notify physicians when ordered medications were not available for three residents, contrary to the facility’s Medication Orders policy requiring nursing to contact the prescriber when delivery of a medication will be delayed or the medication is not or will not be available. For a moderately cognitively impaired resident, the physician had ordered hydrochlorothiazide for hypertension and MiraLAX for constipation; the MAR showed multiple dates in which these medications were marked as not available, and nurse notes for the same period contained no documentation that the physician or pharmacy had been contacted. A cognitively intact resident had multiple ordered medications, including hydrochlorothiazide, cyclobenzaprine, Boost, lemon drops, ferrous gluconate, rosuvastatin, and vitamin B12. The MAR documented several of these medications as not available on multiple dates, yet nurse notes did not show any physician notification. A severely cognitively impaired resident had orders for colestipol, donepezil, Eliquis, potassium chloride, methenamine hippurate, and vitamin C; the MAR documented repeated instances of these medications being unavailable across many days, including Eliquis and potassium chloride, without corresponding documentation in nurse notes that the physician was contacted when the medications were not administered. In interviews, a CMT stated staff would report unavailable medications to the charge nurse, and the ADON and DON stated nurses should contact the physician and pharmacy when medications are not available, indicating this did not occur as required.
Failure to Safeguard Resident Funds and Investigate Reported Misappropriation
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from misappropriation of funds and did not follow required abuse/misappropriation reporting and investigation protocols. The resident’s quarterly MDS documented that the resident was cognitively intact. At admission, the resident had $1700 in cash, described as $100 bills, which the resident reported giving to a staff member in the business office to be placed in an account for the resident’s use. RN A, who completed the admission, stated that he/she took the resident to the Business Office Manager’s (BOM) office, witnessed the resident hand the $1700 in cash to a staff member, and heard the staff member tell the resident the money would be put into an account for the resident. Review of the resident’s funds account showed no deposit of $1700 during the period reviewed. Multiple staff and family reports about the missing $1700 were made over several months without a timely or thorough investigation by the administrator. The Activity Director reported that in early August, during an admission activity assessment, the resident stated he/she had given $1700 in cash to a staff member on the day of admission and did not know what happened to the money; the Activity Director reported this concern to the administrator. The Social Service Director (SSD) D stated that shortly after starting in September, the resident’s family member asked about the missing $1700, and a former staff member told them the facility was investigating it. SSD D further reported that in October, he/she and the resident’s family member spoke directly with the administrator, in front of the receptionist, about the missing money. The receptionist confirmed witnessing SSD D and the family member inform the administrator about the missing funds and stated the administrator had been made aware of the issue even before that conversation. Despite these reports, the administrator did not initiate an investigation or notify the state agency when first informed of the missing money. The Assistant Director of Nursing (ADON) stated that he/she was aware of the resident’s report of missing money several months earlier and had asked the administrator if assistance was needed, but the administrator responded, “the less you know the better,” and the ADON heard nothing further. The administrator later acknowledged being told about the missing money, though not the exact amount, and admitted he/she did not investigate or report the allegation to the Department of Health and Senior Services at that time, stating he/she should have done so. The facility’s Abuse Prohibition Protocol required that allegations of abuse, neglect, misappropriation, or exploitation be thoroughly investigated with documented resident, staff, and witness statements, environmental review, physical assessment, and a timeline of events. These required investigative steps were not initiated when the allegation was first reported, leading to a prolonged period during which the resident’s missing funds were not addressed in accordance with facility policy and regulatory expectations. When the Director of Operations (DOP) was later informed by SSD D that the resident and family had repeatedly reported the missing $1700 and that the administrator had been previously notified without action, the DOP began an investigation and notified the state agency. The DOP determined through interviews that the resident had $1700 in cash at admission and had given it to a staff member, but the funds were never deposited into the resident’s account. The corporate financial representative and BOM also interviewed the resident, who again reported bringing $1700 in cash at admission, taking it to the office, and giving it to a staff member whose name he/she could not recall, though the resident could identify the office location. Former SSD E denied receiving any cash from the resident and stated that if he/she had, it would have been secured in the facility safe with a witness. Overall, the documented events show that the facility failed to safeguard the resident’s funds and failed to promptly and thoroughly investigate and report the allegation of misappropriation as required by its own abuse and misappropriation protocols.
Failure to Timely Report Alleged Misappropriation of Narcotic Medication
Penalty
Summary
Facility staff failed to report an allegation of misappropriation of a resident’s narcotic medication to the state agency within the required 24-hour timeframe. The facility’s Abuse Prohibition Protocol Manual requires the Administrator or designee to report allegations to the State Survey Agency within two hours if abuse or serious bodily injury is involved, or within 24 hours if the event did not involve abuse or serious bodily injury. Resident #1’s quarterly MDS dated 12/25/25 showed the resident was moderately cognitively impaired, received PRN pain medication during the seven-day look-back period, and used an opioid medication. The resident’s POS for 10/01/25–10/31/25 included an order for Morphine concentrate solution 100 mg/5 ml every four hours as needed for pain. During a narcotic count in October, an LPN observed that Resident #1’s liquid Morphine bottle, received in June, had a broken seal and the liquid appeared clear instead of the expected pink color, leading the LPN to believe the bottle was full of water. The LPN reported this to the ADON. The pharmacist later confirmed that the Morphine solution should remain pink and that water entering the bottle would dilute the color. The ADON stated that the LPN reported the potential missing doses and possible misappropriation to him/her, and that he/she then reported this potential misappropriation to the Administrator. The Administrator and ADON both acknowledged that the Administrator was responsible for reporting allegations of misappropriation of property to the Department of Health and Senior Services within 24 hours, but the Administrator did not remember if DHSS was contacted, and the ADON did not know if the allegation was reported. The DON, who was not employed at the time of the incident, confirmed that staff are directed to report abuse and neglect immediately to a supervisor or the Administrator and that the Administrator is responsible for reporting misappropriation allegations to DHSS within 24 hours.
Failure to Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an allegation of misappropriation of a resident’s narcotic medication. The facility’s Abuse Prohibition Protocol Manual requires that all alleged violations of abuse, neglect, misappropriation, or exploitation be thoroughly investigated with documented evidence such as resident, witness, and staff statements, environmental review, resident physical assessment, and a clear timeline of events. The facility’s Narcotic Count policy further requires that any narcotic count discrepancy be reconciled with the off‑going nurse remaining on duty, the DON notified, and an investigation initiated to determine the cause of the discrepancy. Despite these policies, the medical record for the period reviewed contained no documentation that an investigation was conducted regarding the alleged misappropriation of the resident’s liquid morphine. The resident involved was assessed on a quarterly MDS as moderately cognitively impaired, having received PRN pain medication in the look‑back period, and using an opioid medication. The resident had an order for morphine concentrate solution 100 mg/5 ml to be given every four hours as needed for pain. An LPN reported that during a narcotic count, the seal on the resident’s liquid morphine bottle—received months earlier and reportedly never used—was found broken and the liquid appeared clear instead of the expected pink, leading the LPN to believe the bottle contained water. The LPN reported this to the ADON. The pharmacist later confirmed that morphine solution should remain pink and that dilution with water would lighten the color. The administrator stated that he and the ADON were responsible for thorough investigations of misappropriation allegations and that the ADON had investigated and found the allegation unsubstantiated; however, the ADON reported being unable to locate any paperwork related to this investigation, and the resident’s record contained no evidence of a completed investigation.
Failure to Notify Physician and Family After Resident Change in Condition
Penalty
Summary
Facility staff failed to notify residents' representatives and/or physicians after significant changes in condition for three out of five sampled residents. For one resident with severe cognitive impairment, staff did not document notification to the physician or family after two separate falls, and the family later reported not being informed about the fall or subsequent hospital transfer. Progress notes also indicated the family expressed concerns about lack of communication regarding one of the falls during a care plan meeting. Another resident, assessed as cognitively intact, experienced a fall, but there was no documentation that the physician or family were notified. Event reports and progress notes for these incidents lacked evidence of required notifications. A third resident experienced a significant weight loss of 7.62% over a short period, but the medical record did not show that the family or representative was notified of this change. Interviews with staff, including an LPN, the administrator, and the DON, confirmed that the facility's protocol is to notify the physician and responsible party after a change in condition, but the facility was unable to provide a policy for this process. The facility census at the time was 80.
Failure to Update and Revise Care Plans After Significant Changes
Penalty
Summary
Facility staff failed to review and update care plans in response to changes in residents' care needs for multiple residents. Specifically, staff did not revise care plans after significant events such as falls or notable weight loss, nor did they consistently update care plans on a quarterly basis as required by facility policy. For example, one resident experienced a fall that resulted in an emergency room visit, but the care plan was not updated with new interventions following the incident. Another resident experienced a 5.7% weight loss in one month, but the care plan was not updated to address this change until over a month later, and there was no physician order to monitor or address the weight loss. Additionally, care plans for two residents were not updated quarterly as required. Interviews with the administrator and DON confirmed that care plans should be updated after significant changes, quarterly, and annually, and that new interventions should be added after events such as falls or significant weight changes. Both acknowledged that the MDS Coordinator and nurses are responsible for these updates, and that the DON is responsible for auditing care plans to ensure compliance. The DON admitted there was no excuse for the oversight in not verifying that care plans were updated after significant changes or on a quarterly and annual basis.
Employment of Staff with Disqualifying Criminal Conviction
Penalty
Summary
Facility staff failed to ensure compliance with hiring protocols by employing an individual with a disqualifying criminal conviction. Specifically, a certified nursing assistant (CNA) was hired despite having a Class A Felony conviction for First Degree Assault involving serious physical injury or a special victim, which is a disqualifying factor for employment in the facility. The facility's Abuse Prohibition Protocol Policy prohibits the employment of individuals found guilty of abuse or with abuse violations against their professional license, and the Hiring Process Policy requires checks of the Employee Disqualification List (EDL) and the Family Safe Care Registry (FSCR) for all potential hires. A review of the CNA's personnel file confirmed the hire date and revealed that the required criminal background check (CBC) conducted at the time of employment did not identify the disqualifying crime, as the facility relied on a private investigation firm rather than the mandated FSCR. It was only upon a subsequent CBC request that the disqualifying conviction was discovered. Interviews with facility staff indicated that the receptionist was responsible for conducting CBCs and that the oversight occurred prior to the current administrator's tenure, with the proper registry not being used during the initial hiring process.
Failure to Provide Bed Hold Policy Notification at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to the hospital for three out of four sampled residents. According to the facility's own Bed Hold Policy Guidelines, notification is required upon admission, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. Record review showed that for three residents, there was no documentation that a bed hold notice was issued during multiple hospital discharges and readmissions. Interviews with the residents confirmed that they did not receive a bed hold notice at the time of their transfers. Further interviews with facility staff, including the ADON, SSD, DON, and the administrator, revealed that the responsibility for issuing and filing the bed hold notice lies with the charge nurse, with follow-up by the SSD. However, staff were unaware that some notices had not been issued, and there was no clear process to double-check that the notices were consistently provided and documented. The facility census at the time was 88.
Failure to Administer Pain Medications and Reassess Smoking Privileges
Penalty
Summary
Facility staff failed to ensure that a resident received pain medications as ordered following the postponement of a scheduled surgery. The resident, who was cognitively intact and diagnosed with Parkinson's Disease and osteoporosis, had a care plan that included scheduled and PRN pain medications. After the surgery was canceled, staff did not obtain a physician's order to resume medications that had been placed on hold, nor did they document an order for the medication holds or their resumption. The electronic Medication Administration Record (eMAR) showed that pain medications such as Tizanidine and Hydrocodone/Acetaminophen were not administered on several occasions, with reasons documented as either "not available" or "on hold." The resident and family were told by charge nurses that no medications were on hold, but the resident later learned from a Certified Medication Technician that Tizanidine was on hold, resulting in unmanaged pain and confusion about medication administration. Interviews with staff revealed a lack of clarity and communication regarding medication holds and resumption after surgery cancellation. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that medication holds were not properly managed and that staff did not obtain the necessary physician orders. The DON stated that medication holds and resumptions were typically communicated during shift reports or through notes, but this process failed when the nurse responsible for the holds left the facility. Additionally, staff did not utilize the STAT box to obtain unavailable pain medication, further contributing to the resident not receiving prescribed pain management. The facility also failed to complete and document smoking risk assessments to re-assess smoking privileges for two residents who smoke. Despite incidents where one resident was observed smoking inside the building and another was involved in a dispute over cigarettes, there was no documentation of re-assessment of their smoking privileges in the electronic medical record. Interviews with staff and administration indicated confusion over who was responsible for completing smoking assessments, with inconsistent practices and lack of follow-through when incidents occurred.
Failure to Enforce Smoking Material Policies Creates Accident Hazard
Penalty
Summary
Facility staff failed to ensure the environment was free from accident hazards by not enforcing policies regarding the retention of smoking materials among residents. The facility's admission packet and smoking policy clearly state that residents may not retain matches or lighters, and that staff are to confiscate such items if found. However, two residents were allowed to keep cigarettes and lighters in their possession, contrary to facility policy and their care plans. One resident, assessed as cognitively intact and a safe smoker, was observed lighting a cigarette in the dining room, an area where smoking is prohibited, and was found with lighters in his possession. Staff interviews revealed uncertainty about whether the resident still had access to smoking materials, and the resident himself confirmed keeping cigarettes and a lighter in his room. The care plan for this resident did not include any interventions or restrictions related to smoking, despite incidents of unsafe smoking behavior in the facility. Another resident, whose cognition was not assessed but was also documented as a safe smoker, was observed in the dining room with cigarettes and a lighter visible in a waist pouch, despite a care plan stating that these items should be kept at the nursing station and that smoking should be supervised. Staff interviews indicated a lack of clarity and consistency regarding which residents were permitted to retain smoking materials and where these items should be stored, leading to lapses in supervision and enforcement of safety protocols.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility staff failed to conduct quarterly assessments using the Minimum Data Set (MDS) for 19 residents out of a sample of 20, as required by federal regulations. The assessments were not completed within the mandated 92-day interval, as outlined in the Resident Assessment Instrument (RAI) manual. This deficiency was identified through interviews and record reviews, revealing that the MDS assessments for these residents were not documented in the months of July and August 2024. The facility census at the time was 83 residents. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Nursing (ADON), and the administrator, highlighted that the previous MDS Coordinator had been frequently absent, leading to a backlog in MDS assessments. The current MDS Coordinator is attempting to catch up on the overdue assessments. The ADON indicated that the Director of Nursing (DON) is responsible for oversight of the MDS process, but the DON has been occupied with covering RN hours on the floor, limiting their availability. The administrator was unaware of the extent of the backlog and noted that corporate oversight had not reported the issue.
Inadequate Water Management Program Leads to Legionella Risk
Penalty
Summary
The facility failed to develop and implement comprehensive policies and procedures for the inspection, testing, and maintenance of its water systems to prevent the growth of waterborne pathogens, specifically Legionella. The facility's water management program lacked essential components such as control measures, corrective actions, and specific testing protocols. The program did not include policies related to water management, and the facility only planned to test the water if a positive case of Legionnaire's disease occurred. The water system description identified areas where Legionella could grow, such as temperature permissive water heaters and areas of possible stagnation, but did not address system dead legs or include necessary control measures. Interviews with facility staff revealed a lack of awareness and understanding of the water management program and its requirements. The maintenance director admitted to not testing the water for Legionella and was unaware of specific water management policies. The maintenance director also lacked knowledge about terms like temperature permissive and special considerations for healthcare facilities. The Infection Preventionist was not familiar with the water management program, and the administrator acknowledged not having reviewed the program in depth. The facility's control measures were limited to monitoring water temperatures and visual inspections, with no documentation of corrective actions. A resident was sent to the hospital with respiratory distress and tested positive for Legionella, highlighting the facility's failure to adequately manage its water systems. The facility's water management plan did not include facility-specific policies, control measures, or corrective actions, and there was no documentation of water flushing or other preventive measures. The lack of a comprehensive water management program and the staff's limited understanding of the requirements contributed to the deficiency, putting residents at risk of exposure to Legionella and other waterborne pathogens.
Failure to Conduct Background Checks and Investigate Resident Injury
Penalty
Summary
The facility failed to conduct proper background checks on five employees, including a Dietary Aide, Nurse Aide, Housekeeping staff, another Dietary staff, and a Registered Nurse, out of a sample of ten employees. The facility's Screening Abuse and Neglect Manual mandates that all applicants must be checked against the Certified Nurse Assistant (CNA) Registry before hire to ensure they do not have a Federal Indicator for abuse or neglect. However, the assistant business office manager (ABOM) was unaware of the requirement to run CNA registry checks on all staff, not just CNAs, leading to the oversight. Interviews with the ABOM, Assistant Director of Nursing (ADON), and the Administrator revealed a lack of awareness and communication regarding the necessity of these checks. Additionally, the facility failed to investigate an injury of unknown origin for a resident. The resident, who had intact cognition, required substantial assistance with lower body dressing, had an upper extremity impairment, and used a wheelchair, was observed with a red left cheek, swelling under the left eye, a laceration on the forehead, and a swollen left wrist and hand. Despite these injuries, there was no documentation of an investigation into their cause. The ADON acknowledged being informed of the injuries but did not conduct a formal investigation or fill out a report, failing to follow the facility's protocol for investigating injuries of unknown origin. The Administrator expected the charge nurse to initiate an investigation, notify relevant parties, and document the findings, but this process was not followed. The lack of investigation and documentation left the cause of the resident's injuries unexplored, and the Administrator was not informed of the incident. This oversight highlights a breakdown in communication and adherence to established procedures for handling injuries of unknown origin within the facility.
Inconsistent Treatment and Code Status Documentation
Penalty
Summary
The facility staff failed to meet professional standards of care for Resident #31 by not providing the prescribed treatment as ordered. The resident, who has moderate cognitive impairment, lower extremity impairment, and diagnoses of Parkinson's and Diabetes, had a physician's order for Tubi grip to be applied to both lower extremities every shift and removed at bedtime for generalized edema. However, observations on multiple occasions showed the resident without the Tubi grips. Interviews with staff revealed that the resident often refused to wear the Tubi grips, but there was a lack of documentation regarding these refusals and no notification to the physician, as required by the facility's policy. Additionally, the facility staff failed to provide consistent documentation regarding the code status for two residents. Resident #3 was assessed as having moderate cognitive impairment, with conflicting documentation showing both full code status and do not resuscitate (DNR) status. Similarly, Resident #30, who was cognitively intact, had discrepancies in documentation, with records showing both full code and DNR status. Observations noted the use of colored stickers on residents' doors to indicate code status, but there was confusion among staff about their meaning, and the documentation did not consistently match the residents' wishes. Interviews with various staff members, including the social services director and the assistant director of nursing, highlighted a lack of awareness regarding the inconsistencies in code status documentation. The social services director, responsible for maintaining and updating advance directives, admitted to not being aware of the discrepancies and acknowledged that audits were not conducted frequently enough to ensure accuracy. The administrator also expressed concern that inconsistent records could lead to residents' wishes not being upheld in an emergency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule for July, August, September, and early October 2024 showed multiple days without RN coverage for the required hours. Specifically, there were numerous days in July and August where no RN was present, and in September, the facility did not have an RN for eight consecutive hours per day. The issue persisted into October, with no RN coverage from October 1st to October 8th. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the administrator revealed that the facility only had one full-time RN, who was the DON. The DON worked 12-hour night shifts to cover gaps in nursing coverage and was on call when not scheduled. The ADON, responsible for scheduling, acknowledged the requirement for RN coverage but cited cost issues with using agency staff. The administrator confirmed the staffing situation and the facility's awareness of the requirement for RN coverage.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility staff failed to adhere to their policies and procedures for immunizing residents against Pneumococcal disease, as evidenced by the lack of documentation and administration of vaccines to two residents. The facility's policy required consultation with the resident's physician to determine the need for vaccinations and a physician's order to administer them. However, the records for two residents, one admitted with a signed pneumococcal vaccination consent, showed no documentation of the vaccine being offered, received, or refused. Another resident, who had previously received a PCV13 vaccine, also had a signed consent but lacked documentation of being offered or receiving the recommended PCV20, PCV21, or PCV23 vaccines. Interviews with the Assistant Director of Nursing/Infection Preventionist and the administrator revealed a lack of oversight and follow-through in the immunization program. The Infection Preventionist admitted to not keeping up with offering pneumococcal boosters since taking on the role and was unaware of why some residents were not vaccinated. The administrator confirmed that the Infection Preventionist was responsible for the vaccination program and acknowledged that the immunization policy was not followed, agreeing that eligible residents should have been offered the vaccines.
Failure to Complete Discharge Summary and Plan
Penalty
Summary
Facility staff failed to complete a comprehensive discharge summary or post-discharge plan of care for a resident who was discharged. The facility's policy requires staff to provide a discharge summary and post-discharge plan to ensure a safe departure and sufficient aftercare information. However, the medical record of the discharged resident did not contain these documents. Interviews revealed that the Social Services Director (SSD) was responsible for completing the discharge summary and other discharge information but admitted to not doing so. The Assistant Director of Nursing (ADON) confirmed that the SSD is responsible for setting up home health or therapy if needed and for discharge education. The facility administrator also expected the SSD to ensure discharge information was documented in the resident's medical record.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
Facility staff failed to provide appropriate care and services for a resident requiring hemodialysis, as they did not adhere to professional standards of practice. The facility's policy for dialysis care included daily checks for thrill, inspection of the access site for signs of infection, and maintaining communication with the dialysis unit. However, the resident's medical records lacked documentation of these assessments, including monitoring vital signs, shunt condition, and daily weights. Additionally, there were no physician orders for dialysis or care of the shunt, and communication forms were not completed. Interviews with facility staff revealed a lack of awareness and adherence to the dialysis care policy. Charge Nurse L only documented issues if reported by the dialysis clinic, while LPN A was unaware of the policy and the need for pre- and post-dialysis assessments. The ADON acknowledged the absence of orders and assessments, attributing it to a lack of staff education and oversight. The administrator was also unaware of the deficiencies in documentation and communication, despite expectations for proper orders and assessments.
Medication Administration Errors Result in 6.45% Error Rate
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a 6.45% error rate during the observation of 31 medication administration opportunities. Two errors were identified, affecting one resident diagnosed with Dementia/Alzheimer's, hypertension, and a hip fracture. The first error involved a Certified Medical Technician (CMT) crushing Metoprolol Succinate ER tablets, which should not be crushed as per the medication guidelines. The CMT acknowledged the mistake, realizing that the extended-release nature of the medication was compromised, potentially leading to the full dose being administered at once. The second error occurred when the same CMT administered Latanoprost eye drops to both eyes of the resident, despite the physician's order specifying administration to the left eye only. The CMT admitted to not reviewing the updated medication administration record closely enough, which led to the error. Interviews with the Assistant Director of Nurses (ADON) and the administrator confirmed that extended-release medications should not be crushed and that medication errors should be reported to the Charge Nurse and discussed in QAPI meetings. The Charge Nurse emphasized the importance of following medication orders as written.
Lack of Hospice Care Documentation for Residents
Penalty
Summary
The facility staff failed to document collaboration of care with hospice providers for the development and implementation of a coordinated plan of care and communication between the facility and local hospice provider for two residents receiving hospice services. The facility's Nursing Facility Services Agreement mandates regular communication and documentation between the hospice and the facility to ensure the needs of hospice patients are met continuously. However, for Resident #49, who had a diagnosis of cancer and a life expectancy of less than six months, and Resident #82, who had a diagnosis of kidney disease, there was no documentation of a plan of care or communication between the facility and the hospice provider in the hospice binder or the residents' medical records. Interviews with facility staff, including an LPN, the Assistant Director of Nursing (ADON), and the administrator, revealed an expectation for hospice communication and care plans to be documented in the hospice binder at the nurses' station. Despite these expectations, the documentation was missing, and the ADON acknowledged previous discussions with hospice about this issue, though it remained unresolved. The administrator also confirmed the expectation for documentation of hospice visits, changes in condition, and care plans, which were not present in the records reviewed.
Medication and Treatment Carts Left Unlocked and Unattended
Penalty
Summary
Facility staff failed to store medications and biologics safely, as observed when medication and treatment carts were left unlocked in public areas accessible to residents. The facility's policy mandates that all medications be stored in locked cabinets, medication rooms, or carts, and that hazardous substances be kept in separate locked containers. However, observations on multiple occasions showed the 200 hall medication cart and the 300 hall treatment cart left unlocked and unattended in the hallways. Interviews with facility staff, including a Certified Medication Technician, a Charge Nurse, the Assistant Director of Nurses, and the administrator, confirmed that medication and treatment carts should always be locked unless staff are directly in front of them. The staff acknowledged the potential for residents to access the carts or for drugs to be misplaced, indicating a clear understanding of the policy and the associated risks. Despite this, the carts were repeatedly found unsecured, highlighting a failure to adhere to the facility's medication storage policy.
Failure to Document Physician-Ordered Wound Care
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not documenting the provision of wound treatment for one resident, as ordered by the physician. The facility's policy on physician orders lacked specific guidance on ensuring accuracy when transcribing these orders into the resident's medical records. A review of the resident's medical records revealed that a physician's order for wound care, dated 07/17/24, was not documented in the Physician Order Sheet (POS) for the period of 07/02/24 through 08/01/24. This oversight occurred despite the resident being assessed as cognitively intact and having a specific wound care regimen prescribed by the physician. Interviews with facility staff, including an LPN and the administrator, highlighted that both nurses and the Director of Nursing (DON) were responsible for inputting and verifying orders in the resident's medical records. However, the LPN was unaware of any order to cover the resident's wounds with a dressing after surgery on 07/14/24. The administrator confirmed that the charge nurse or DON was expected to accurately enter orders into the medical records, and acknowledged the potential risk of the wound not healing or becoming infected if wound care orders were not followed.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility staff failed to revise the care plans for three residents following falls, as required by their policy. The policy mandates that the Minimum Data Set (MDS) Coordinator is responsible for updating care plans with new interventions after a fall. However, the care plans for the residents did not reflect any new interventions after their falls. Resident #1, with moderate cognitive impairment, had an unwitnessed fall documented in their medical records, but their care plan lacked any new intervention. Similarly, Resident #2, with severe cognitive impairment, experienced an unwitnessed fall, yet their care plan was not updated with new interventions. Resident #3, who is cognitively intact, had both a non-injury fall and a fall with injury, but their care plan also did not include any new interventions. Interviews with facility staff revealed a lack of clarity and accountability regarding the updating of care plans. The MDS Coordinator acknowledged the responsibility to update care plans but admitted to possibly missing updates due to personal health issues. The Director of Nursing (DON) and the administrator both confirmed that the MDS Coordinator was responsible for updating care plans and that daily meetings were held to discuss falls and interventions. However, there was confusion about who was responsible for auditing the care plans for accuracy, with the DON believing it might be the corporate nurse's responsibility. This lack of oversight and communication led to the deficiency in updating the care plans after falls.
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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