Worth County Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grant City, Missouri.
- Location
- 503 East Fourth, Grant City, Missouri 64456
- CMS Provider Number
- 265773
- Inspections on file
- 16
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Worth County Convalescent Center during CMS and state inspections, most recent first.
Staff failed to follow professional standards and physician orders in several areas, including wound care, LAL mattress use, and insulin administration. A resident with stage 3 pressure ulcers did not consistently receive ordered peri-wound skin prep and zinc spray during dressing changes, as observed when an RN completed a dressing change without applying the sprays and did not return after being questioned. Another resident at risk for pressure ulcers used a LAL mattress that was repeatedly observed set at 350 pounds, with no corresponding physician order, no care plan entry for the mattress, and no clear staff responsibility for checking settings. Multiple residents with diabetes received insulin from pens that lacked proper labeling and open dates, and an LPN repeatedly did not clean the pen port or prime the pen before administration, while also misunderstanding when priming was required; the DON later described correct labeling, dating, port cleaning, and priming procedures that were not followed.
Failure to Obtain Written Consent for Psychotropic Medications: The facility did not document written consent before starting psychotropic meds for four residents. Records showed no informed consent for antipsychotic, antidepressant, or anticonvulsant use for residents with diagnoses including dementia, stroke, depression, psychotic disorder, and impaired cognition. The DON and Administrator acknowledged that written consents should have been in the medical record.
Resident Trust Fund Accounting Deficit: The facility failed to maintain a full and separate accounting of resident trust funds when monthly bank paper statement fees were charged to the account but not reimbursed by the facility. The resident trust fund reconciliation showed a growing deficit owed by the facility, with interest credited only on the ending balance and not on the funds the facility owed. Four residents were affected, including residents who were cognitively intact and others with dementia, Alzheimer’s disease, stroke, quadriplegia, and other chronic conditions.
The facility failed to develop comprehensive person-centered care plans for two residents. One resident’s care plan did not include the resident’s goal to return to the community, despite being cognitively intact and stating that goal during interview. Another resident’s care plan did not address DNR/code status, even though the face sheet and physician orders reflected DNR and the DON stated care plans should address code status.
Insulin Pen Administration Errors: Staff failed to clean insulin pen ports and prime the pens with two units before administering insulin to three residents. Observations showed an LPN administering Humalog or Lispro without priming the pen or cleaning the port, despite orders for blood sugar monitoring and scheduled insulin doses. The DON stated staff should clean the port with alcohol and prime the pen with two units each time before use.
Medication Labeling and Storage Deficiencies: Staff pre-poured medications for several residents, taped punctured Lorazepam doses back into a bubble pack, and kept multiple insulin pens without proper open-date labeling. An opened bottle of morphine sulfate was also found undated. The DON and an LPN acknowledged the improper medication handling and labeling.
Food storage temperatures were not properly monitored or documented. In the kitchen, multiple refrigerators and freezers had no temperature logs, and the chest freezer thermometer was buried under frozen food. The DM said staff were supposed to check the thermometer but it often got covered after deliveries, and dietary temperature sheets were no longer being used. The DON stated temperatures should be checked and recorded daily, but prior logs showed missing entries, no initials, and long gaps with no documented readings.
Failure to complete required TB screening for new hires: the facility did not follow its TB policy for multiple employees by allowing baseline testing to occur after hire, reading one TB test too early and another too late, and lacking updated TB documentation for a CNA on file. The DON stated TB tests read outside the 48- to 72-hour window are invalid, and the Administrator said she could not explain why one CNA lacked pre-employment TB testing and another CNA’s documentation could not be located.
A resident's credit card was used without authorization for multiple purchases, totaling over $300, after being kept in an unlocked dresser drawer. The resident, who had no cognitive impairment and required staff supervision for ADLs, was unaware the card was missing until notified by their financial POA. Facility staff were not aware the resident had a debit card, and the required comprehensive investigation was not conducted according to policy.
A resident with no cognitive impairment and multiple medical diagnoses experienced unauthorized charges on their debit card, which was kept in an unlocked dresser. The facility Administrator, after being notified by the resident's POA, failed to conduct a thorough investigation as required by policy, only interviewing the resident and family and not documenting when the card was last in the resident's possession. Staff were unaware of the card, and the Sheriff's office was notified.
The facility failed to update care plans with fall interventions for four residents who experienced falls. Despite multiple incidents, no new interventions were documented, leaving the residents at ongoing risk.
A facility failed to investigate an injury of unknown origin for a resident with dementia, resulting in extensive bruising. The facility did not follow its abuse and neglect policy, failed to interview all staff and residents, and did not document the investigation. The resident required substantial assistance with daily activities and had a history of dementia and other medical conditions.
Failure to Follow Wound Care Orders, LAL Mattress Parameters, and Insulin Pen Standards
Penalty
Summary
The deficiency involves multiple failures to follow professional standards of practice and physician orders for wound care, low air loss (LAL) mattress use, and insulin administration. One resident with two stage 3 pressure ulcers on both buttocks had physician orders for licensed nursing staff to clean the wounds with wound cleanser, use skin prep to the peri-wound area, apply collagen powder, and cover with bordered gauze on specified days, as well as to apply a zinc spray to the peri-wound area with dressing changes and daily. During an observed dressing change, the RN removed intact dressings, cleansed the wounds, applied collagen powder, and covered them with bordered gauze, but did not apply the ordered skin prep spray or zinc spray to the peri-wound area. When questioned afterward, the RN stated they believed the sprays were only done with morning and night dressing changes and did not return to complete the ordered treatment. The resident reported that staff were supposed to check the dressings every day shift and apply spray, but that this was rarely done and that primarily one LPN applied the spray. The DON confirmed that the RN should have completed the entire ordered treatment, including the sprays, and that nursing staff should perform treatments as ordered and according to the schedule. Another deficiency involved the use and management of a LAL mattress for a resident who was cognitively severely impaired, dependent on staff for most ADLs, always incontinent, and at risk for pressure ulcers. The resident’s care plan did not address the use of a LAL mattress, and the physician orders contained no order for a LAL mattress or its settings. Multiple observations over several days showed the resident either in bed or out of bed with the LAL mattress consistently set at 350 pounds. When interviewed, an LPN stated they did not know who was responsible for checking the LAL mattress settings and thought it might be housekeeping. The Administrator stated that if a resident was on hospice, hospice should monitor to ensure the LAL mattress was on the correct setting. The facility did not provide a policy for the Drive LAL mattress. Additional deficiencies were identified in insulin administration practices for several residents with diabetes mellitus. For one resident who was cognitively intact and independent with ADLs, orders included blood sugar checks twice daily and Humalog insulin 12 units three times daily with meals. Observation showed the resident checked their own blood sugar and reported a value of 184 to an LPN. The Humalog pen used had no pharmacy label, no open date, and only a handwritten first name and dose on the lid. The LPN did not clean the pen port before attaching the needle, did not prime the pen with two units, and then dialed and administered 12 units. For another cognitively intact resident with diabetes, orders included blood sugar checks before meals and at bedtime and Humalog 8 units three times a day. Observation showed the LPN obtained a blood sugar of 116 and used a Humalog pen that lacked a proper label and open date, with only handwritten initials and dose on the lid. Again, the LPN did not clean the port or prime the pen before dialing and administering 8 units. A further observation of insulin administration for another resident showed the same LPN preparing to administer 12 units of insulin from a pen that had no open date written on it. The LPN had already attached the needle and drawn up the dose without priming the pen or cleaning the port. In a subsequent interview, the LPN stated they believed priming was only necessary when the pen was first opened and described their procedure as simply screwing on the needle and dialing the required amount, without mentioning port cleaning. The LPN acknowledged that insulin pens should be dated when opened. The DON stated that insulin pens should be labeled with the resident’s name, not used if not dated or labeled, the port should be cleaned with alcohol before attaching the needle, and the pens should be primed with two units before each use. The facility did not provide a policy for the use of insulin pens, although existing policies required that physician orders be followed as written and that wound care procedures include applying prescribed medications to the wound or wound area if ordered.
Failure to Obtain Written Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks and benefits of proposed care by not obtaining written consent before starting psychotropic medications for four sampled residents. The facility policy stated residents or representatives have the right to be informed in advance of the risks and benefits of proposed care or treatment. Review of records showed no documentation of informed consent for the use of psychotropic medications for Resident #3, Resident #4, Resident #5, and Resident #30. Resident #3 had severe cognitive impairment, dementia, psychotic disorder, and stroke, and was ordered Quetiapine Fumarate and Divalproex Sodium for mood disorders beginning 10/16/24, but no informed consent from the resident or family was found. Resident #4 was cognitively intact and had depression, muscle wasting and atrophy, and wound infection; Aripiprazole and Sertraline were ordered on 08/15/24, but no consent was located. Resident #5 was cognitively intact with dementia, depression, and stroke; Sertraline was ordered on 03/04/24 and Quetiapine Fumarate on 07/11/25, with no consent documented. Resident #30 had moderately impaired decision-making, Alzheimer’s disease, stroke, depression, and non-traumatic brain dysfunction; Seroquel 50 mg at bedtime was started on 12/16/25, and the electronic chart contained no consents or education on risks and benefits. The DON and Administrator stated that written consents should have been in the medical record.
Resident Trust Fund Accounting Deficit
Penalty
Summary
The facility failed to establish and maintain a system that provided a full and complete separate accounting of residents’ personal funds entrusted to the nursing home. Monthly personal funds reconciliation showed an accumulating reimbursement deficit in the resident trust fund account because monthly bank charges for a paper statement fee were not reimbursed by the facility. The resident trust fund account review from February 2025 through January 2026 showed a $2.00 monthly fee charged each month, no entries showing reimbursement for those bank charges, and a running balance of money owed by the facility that reached $84.00. Interest was credited monthly based on the ending account balance, which did not include the funds the facility owed to the account. This affected four of 12 sampled residents: Resident #3, Resident #4, Resident #7, and Resident #12. Resident #3 had diagnoses including hypertension, diabetes, stroke, dementia, quadriplegia, seizure disorder, traumatic brain injury, and psychotic disorder. Resident #4 was cognitively intact and had anemia, hypertension, and GERD. Resident #7 was cognitively intact and had heart failure, hypertension, urinary tract infection, diabetes, dementia, and anxiety disorder. Resident #12 was not cognitively screened and had hypertension, diabetes, Alzheimer’s disease, and depression. During interview, the Administrator stated the facility kept a running tally of the bank statement fees charged to the resident trust fund and that the residents were not responsible for those bank fees, but the account had last been reconciled and reimbursed sometime the prior year.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for two sampled residents. Facility policies stated that care plans should be individualized, include resident goals and desired outcomes, and address the resident’s stated preference and potential for future discharge, including a desire to return to the community. The interdisciplinary team was responsible for developing a comprehensive care plan within seven days of completion of the resident assessment. For Resident #34, the admission MDS showed the resident was cognitively intact and required partial assistance with showering, bathing, and putting on footwear, with setup assistance for most other ADLs; diagnoses included heart failure, chronic lung disease, and kidney failure. The resident’s care plan was revised but did not address the resident’s wish to discharge to the community. During interview, the resident stated the goal was to return to the community and to be able to do things outside the facility. For Resident #29, the care plan did not address code status or the preference for life-saving measures. The face sheet showed DNR, the quarterly MDS showed cognitive skills intact with no behaviors and diagnoses of stroke, depression, and hemiparesis/hemiplegia, and physician orders included DNR. The DON, who was also the MDS/care plan coordinator, stated the care plans should address the resident’s code status.
Insulin Pen Administration Errors
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system free from significant medication errors when staff did not prime insulin pens before administering insulin to three sampled residents. The report states the facility also did not provide a policy for administration of insulin or the use of insulin pens. Resident #2 had orders for blood sugar checks twice daily and Humalog insulin 12 units three times daily with meals; on 2/25/26, staff documented a blood sugar of 184 and insulin administration, and during observation LPN A did not clean the port, did not prime the pen with two units, dialed the pen to 12 units, and administered the insulin in the resident’s right arm. Resident #11 had orders for blood sugar checks before meals and at bedtime and Humalog insulin pen 8 units three times daily; on 2/25/26, staff documented a blood sugar of 154 and insulin administration, and during observation LPN A obtained a blood sugar of 116 but again did not clean the port or prime the pen before dialing to 8 units and administering insulin in the resident’s abdomen. Resident #7 had orders for blood sugar checks twice daily and Lispro insulin 12 units twice daily with meals; on 2/26/26, staff documented a blood sugar of 128 and insulin administration, and during observation LPN A did not clean the port or prime the pen before dialing to 12 units and allowing the resident to administer the insulin to the lower right abdomen. LPN A stated the port should have been cleaned with alcohol and that new insulin pens were primed with two units, but after that the pens were not primed; the DON stated staff should clean the insulin ports with an alcohol wipe and prime the insulin pen with two units each time before use.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles and stored properly, as shown by multiple medication handling errors involving insulin pens, pre-set medications, taped-in tablets, and an undated opened bottle of morphine sulfate. During observation, staff had pre-poured medications into paper cups for three residents, and an LPN acknowledged the medications should not have been preset. The facility also had no policy provided for insulin pens, and several insulin pens for five residents were found with handwritten resident identifiers and dose markings but no date when opened. The DON stated the insulin pens should have been labeled with the resident’s name, date opened, and expiration date. In addition, a resident’s Lorazepam bubble pack contained seven punctured doses that had been taped back into the card, and the LPN stated the medication should have been destroyed by two nurses rather than taped in. Another resident had an opened bottle of Morphine Sulfate that was undated; the bottle had been filled by the pharmacy and later opened, but the facility had no policy for how long it could be used after opening. The LPN stated the morphine should have been dated when opened, and the DON stated the insulin pens should not have been used if they were not dated when opened because there was no way to know how long they had been opened.
Food Storage Temperatures Not Properly Monitored
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety when staff did not properly monitor food storage temperatures. During observation in the kitchen, the chest freezer, two stand-up freezers, two large 2-door refrigerators, and one stand-up refrigerator were missing refrigerator or freezer temperature logs. The chest freezer thermometer was buried beneath frozen food items and had to be dug out by the DM. The facility policy required potentially hazardous foods to be kept out of the temperature danger zone, refrigerators to be maintained at 41 degrees or lower, freezers at 0 degrees, and food temperatures to be checked and recorded regularly. During interview, the DM stated kitchen staff were supposed to look at the thermometer, but after truck deliveries it would get shoved around and covered up. The DM also stated dietary staff did not currently have temperature check sheets and had stopped using them because they were not filled out consistently, although she said she would ask dietary aides if they checked temperatures and that the Dietician checked the thermometers monthly. The Activities Coordinator, who helped in the kitchen, stated kitchen staff should always check and record refrigerator and freezer temperatures. The DON stated temperature checks should be completed daily and recorded by dietary staff. Review of the prior year’s logs showed multiple months with missing entries, no initials, and repeated temperatures that did not vary by one degree, including months with no logs provided and February 2026 with no documented readings until the 22nd.
Failure to Complete Required TB Screening for New Hires
Penalty
Summary
The facility failed to follow its Employee Screening for Tuberculosis (TB) Policy and Procedure by not completing required TB screening for six of 10 employees prior to employment. The policy stated that each newly hired employee must complete a 2-step TB test prior to offer of employment and prior to duty assignment, with baseline testing, individual risk assessment, and symptom evaluation completed before entering the facility. Review of Human Resources and TB records showed that a CNA had TB baseline established 2 days after hire, a dietary employee 11 days after hire, and a nursing assistant 5 days after hire. Another RN’s first-step TB test was read in less than 48 hours, and a second RN’s first-step TB test was read over 72 hours later, outside the stated reading window. Additional record review showed that one CNA hired on 11/13/25 did not have TB baseline established until 1/11/26, 59 days after hire, and another CNA hired on 12/18/25 had only a prior baseline from another facility dated 5/26/22 with no updated TB test on file at the current facility. During interview, the DON stated that TB tests read outside the 48 to 72 hour window are invalid and must be retaken. The Administrator stated that annual tests completed previously by new hires are good for up to one year prior to the date of hire at this facility, that TB tests must be read between 48 and 72 hours after injection, and that she was not sure why one CNA did not have a TB test completed and on file before starting work, while another CNA’s documentation could not be found.
Failure to Prevent Misappropriation of Resident's Credit Card
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's credit card, which was used without authorization by either the resident or the resident's financial guardian. The card was used for multiple unauthorized purchases over several months, totaling $348.23. The resident, who had no cognitive impairment and required staff supervision for activities of daily living, kept the card in a purse inside an unlocked dresser drawer in their room. There were no records indicating when the card was last in the resident's possession or when it was discovered missing. The resident only became aware of the missing card after being informed by their financial power of attorney. The facility's policy required immediate and thorough investigation of financial exploitation, including interviews with all staff and residents, but the Administrator only interviewed the resident and their family. Staff members were unaware that the resident had a debit card, and the facility did not have surveillance cameras. The Administrator was notified of the unauthorized charges by the resident's financial POA and subsequently reported the incident to law enforcement. The investigation by the Sheriff's office was ongoing at the time of the report.
Failure to Investigate and Document Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to follow its policy regarding the investigation and documentation of an alleged misappropriation of a resident's funds. After being notified by a resident's Financial Power of Attorney (POA) about unapproved charges on the resident's debit card, the Administrator only interviewed the resident and the family, without interviewing other staff or residents as required by policy. There was no documentation regarding when the debit card was last in the resident's possession or when it was discovered missing. The facility's policy required a thorough investigation, including interviews with all staff and residents and written statements from involved parties, but these steps were not completed. The resident involved had no cognitive impairment and required supervision for activities of daily living, with diagnoses including anxiety, major depression, unsteadiness, diabetes, and stroke. The resident kept the debit card in a purse inside an unlocked dresser drawer. Bank statements showed multiple unauthorized charges over several months, totaling $348.23. Staff interviewed were unaware the resident had a debit card, and the Sheriff's office was notified of the missing card. The facility census at the time was 27.
Failure to Update Care Plans with Fall Interventions
Penalty
Summary
The facility failed to update and revise the care plans with fall interventions for four residents who had experienced falls. Resident #1 had multiple falls, including one with a head laceration, but no new interventions were documented after each fall. The care plan for Resident #1 was not updated to reflect these incidents and lacked specific steps to prevent future falls. Resident #2 experienced falls while using the toilet and sliding out of a wheelchair, but no new interventions were documented in the care plan after these incidents. The care plan remained unchanged despite the falls, and there was no evidence of steps taken to prevent reoccurrences. Resident #3 and Resident #4 also experienced falls, but their care plans were not updated with new interventions. Resident #3 had abrasions and bruising from a fall, and Resident #4 fell while transferring from the toilet to a wheelchair without assistance. The facility's failure to update care plans with appropriate fall interventions contributed to the ongoing risk of falls for these residents.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury of unknown origin when a resident was found to have extensive bruising across the abdomen, perineal area, and legs. The facility did not implement its abuse and neglect policy, as it failed to interview all staff working at the time, did not interview other residents, and did not provide complete and thorough documentation of the investigation. This affected one of four sampled residents, with a facility census of 27. The resident involved had a history of dementia, myeloma in remission, vitamin D deficiency, and gastroesophageal reflux disease. The resident was dependent on a wheelchair for mobility and required substantial assistance with daily activities. The resident's medical record showed no entries regarding bruising or assessments from the physician or nurse practitioner around the time the bruising was discovered. Interviews with staff revealed that the bruising was first noted on 3/2/24, but no formal investigation was conducted. The Director of Nursing (DON) and Administrator did not document their observations or interviews with staff. The facility's incident reports did not include any report on the injury of unknown origin. Additionally, the facility did not provide specific training on resident care or abuse and neglect upon hire, and no measurements of the bruising were documented.
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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