Amberwood Estates Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 5303 Bermuda Drive, Saint Louis, Missouri 63121
- CMS Provider Number
- 265719
- Inspections on file
- 33
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Amberwood Estates Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain a homelike environment by allowing extremely loud door alarms to sound repeatedly throughout the building, including during meals, without prompt staff response, which residents described as constant and annoying. The facility also did not maintain adequate hot water in several rooms and bathing areas; cognitively intact residents dependent on staff for ADLs reported cold or non-functioning water, and CNAs confirmed that some rooms lacked hot water, that water was sometimes taken from an eye wash station for care, and that residents were not receiving regular showers or bed baths due to cold water. In addition, a resident’s room and bathroom were not thoroughly cleaned, with repeated observations of dark pellet-like debris, accumulated dirt along wall perimeters, and a visibly stained, soiled toilet and surrounding flooring, while the resident reported only brief, inadequate mopping by housekeeping.
Surveyors found that the facility failed to designate and communicate a grievance official and did not make grievance forms or instructions readily accessible. The written policy required 24/7 availability of grievance forms in unsecured common areas, posted information on residents’ rights to file grievances orally, in writing, or anonymously, and clear identification of a grievance official, typically the Social Services Director. However, alert and oriented residents reported they did not know where forms were located, how to file a grievance, or who the grievance official was. Observations showed forms were kept in an unmarked folder in a locked receptionist’s office and only provided on request, with no posted signage about the grievance process. Staff interviews revealed confusion about who served as grievance official after the Social Worker position became vacant, with grievances routed informally through the receptionist, HR, the Activity Director, the Administrator, or the DON without a clearly identified responsible grievance official.
Surveyors found that the facility did not provide or document required bed-hold policy information when residents were transferred to the hospital, despite the Administrator stating that floor nurses were responsible for giving this information at the time of transfer. Review of records showed multiple transfers and discharges with no corresponding bed-hold documentation. In addition, the facility failed to send required copies of discharge notices to the State LTC Ombudsman, even though its written policy required Ombudsman notification for facility-initiated discharges, planned discharges and transfers, and discharges decided while a resident was hospitalized. The last documented Ombudsman notification and transfer log were several months old, and the facility lacked copies of discharge notices for more recent discharges.
The facility failed to provide required showers or baths and to honor resident bathing preferences, resulting in multiple residents not receiving at least two showers or bed baths weekly as required by policy. One resident with mobility impairment and dementia, care planned for twice-weekly assisted showers, had very limited documented bathing and was repeatedly observed with greasy hair, body odor, and unchanged clothing, while reporting infrequent showers due to limited shower room access. Another resident with paraplegia and renal failure, who preferred daily bed baths and required maximal assistance, reported that nonfunctioning or cold water on the unit led to not being offered showers or bed baths, and described an aide refusing to take them to another unit or obtain hot water, then documenting a refusal. A third dependent resident reported avoiding showers because of cold water and resorting to sink bathing, with records showing only one shower, several bed baths, and multiple refusals over many opportunities. Facility leadership acknowledged that residents should have been offered showers or bed baths at least twice weekly and that resident choices, including daily bathing, should have been honored despite water temperature issues.
The facility failed to maintain safe and appetizing food temperatures during tray service, resulting in multiple meals being served either lukewarm, cold, or partially melted. Several cognitively intact residents, including individuals with conditions such as anemia, inflammatory bowel disease, heart failure, malnutrition, renal disease, and diabetes, reported that the food tasted bad, was often cold, or that they avoided eating it. During observed meal services, surveyors and an LPN recorded hot items such as lasagna, chicken bites, and corn at temperatures well below expected hot-holding levels, and cold items such as salad, coleslaw, fruit cups, and sherbet at temperatures that were warm, wilted, or melted, contrary to the facility’s stated expectations for food service.
Surveyors found that staff repeatedly failed to follow the facility’s infection control and EBP policies during high-contact care for multiple residents who were dependent for toileting and personal hygiene and had conditions such as stroke, multiple sclerosis, hemiplegia, cerebral palsy, chronic wounds, and g-tube status. Despite EBP signage and available PPE at room doors, CNAs provided incontinence and peri-care without wearing required gowns, used improper peri-care technique, double gloved, and placed soiled pads and blankets directly on the floor or on another resident’s bed before reusing them. One resident’s care plan called for EBP for a g-tube without a corresponding physician order, and staff interviews confirmed that expected practices—front-to-back peri-care, no double gloving, proper linen handling, and gown and glove use for high-contact care—were not consistently followed in practice.
The facility failed to follow its own policy requiring that nourishing bedtime snacks be offered to all residents unless contraindicated by a physician’s diet order. The policy specified that dietary would stock snacks such as milk, 100% fruit juice, cookies, crackers, and fruit at each nursing station and that nursing staff would pass snacks room to room rather than announcing them from the nurse’s station. Resident Council minutes documented that residents were told there were no snacks at the nurse’s desk and that dietary was not passing out snacks. In a group interview, most alert and oriented residents reported they were not offered bedtime snacks, and one noted that only residents able to walk to the nurse’s station sometimes received snacks. Observations over multiple days showed no snacks at several nursing stations, and the Dietary Manager stated that snacks had not been provided to nursing staff for delivery, affecting all residents who ate at the facility.
Two residents were found living in rooms with significant pest issues, including ants, rat droppings, and water damage, with staff unaware or slow to address the problems. Maintenance logs were not properly used, and cleaning procedures were not followed, resulting in an environment that was neither clean nor homelike.
A resident with cognitive impairment and heel wounds did not receive six ordered doses of Tramadol for pain due to delays in prescription processing and lack of timely physician contact. Staff were unable to access the emergency stock of the medication because the required prescription was not provided to the pharmacy, and documentation inaccurately reflected medication administration when it had not occurred.
The facility did not maintain appropriate hot water temperatures in multiple resident rooms and shower areas, with observed water temperatures consistently below standard levels. Staff interviews revealed that residents had complained about the lack of hot water for months, and CNAs had to take extra measures to provide warm water for bathing. The facility lacked clear policy parameters and regular monitoring, and administrative staff were unaware of the full extent of the issue due to missing documentation and recent changes in management.
The facility failed to monitor and maintain safe water temperatures, resulting in excessively hot water in two resident rooms, and did not conduct a thorough investigation after a resident fall, with missing documentation such as witness statements and neuro checks. Leadership and staff interviews revealed a lack of access to necessary policies and procedures, and required post-fall assessments were not completed.
A resident's personal and medical information was exposed when a medication card was left visible in an unlocked shred bin accessible to staff, residents, and the public. Additionally, an LPN used a personal phone and email to send a photo of the resident's prescription to the pharmacy due to lack of access to secure communication systems. Facility staff and management confirmed that secure procedures and policies for handling confidential information were lacking, and shred bins containing sensitive documents were often unlocked, overflowing, and located in unsecured areas.
A resident with psychiatric and cardiac conditions was slapped by another resident with neurological impairments. Although the incident was witnessed and reported internally, there was no documentation or confirmation that the required report was made to state authorities, and no investigation records were found. Staff interviews indicated uncertainty about whether the abuse was properly reported, resulting in a failure to follow mandated abuse reporting procedures.
The facility did not thoroughly investigate allegations of narcotic misappropriation by an LPN and resident-to-resident physical abuse involving two residents. In both cases, required investigative steps such as obtaining statements, conducting interviews, and documenting findings were not completed, and there was no evidence of a comprehensive investigation as mandated by facility policy.
A resident with multiple pressure ulcers did not receive consistent wound care or weekly wound assessments as ordered, with numerous missed treatments documented. The resident was found with maggots in a wound, and staff confirmed inconsistent dressing changes and lack of wound care policies. The facility lacked a designated wound nurse, and leadership was unaware of the incident and did not investigate.
The facility failed to promote self-determination for residents dependent on staff for transfer assistance by not ensuring they were out of bed daily and did not provide showers per resident preferences. A resident reported being out of bed only twice since admission, and multiple observations confirmed this. Staff interviews revealed that frequent short-staffing hindered their ability to assist residents as needed.
The facility failed to ensure functional bathroom toilets, lights, and call lights for several residents, leading to unsafe and uncomfortable conditions. One resident had to use a shower room down the hallway due to a clogged toilet, while another experienced consistently cold water and a non-functional bathroom light. Additionally, a resident's call light was unreliable, causing delays in receiving assistance. The Maintenance Director admitted to not conducting regular equipment inspections, relying on staff to report issues.
The facility failed to ensure that residents requiring assistance with ADLs received showers as per policy. Multiple residents were observed with poor hygiene and reported not receiving showers for several weeks. Staffing issues and lack of shower sheets were cited as reasons for the deficiency.
The facility failed to ensure proper bed rail assessments and fall interventions for a resident, leading to multiple falls and injuries. Additionally, the facility did not follow safe mechanical lift transfer protocols, failed to complete smoking assessments for two residents, and did not respond promptly to an exit door alarm, highlighting inadequate supervision and safety measures.
The facility failed to maintain adequate staffing levels, resulting in multiple residents not receiving necessary care. One resident, requiring extensive assistance, was repositioned by a single CNA, contrary to their care plan. Another resident had not received a shower for over a month due to staff shortages. A third resident, dependent on staff for ADLs, was found in an unkempt state and had not received scheduled showers. The Regional Nursing Consultant confirmed the facility's staffing was insufficient to meet care expectations.
The facility failed to ensure proper labeling and storage of medications, with multiple instances of opened, undated, and expired OTC medications found in medication carts and a medication room. An unsteady refrigerator storing insulin pens lacked a temperature log sheet. Staff inconsistencies in maintaining medication storage were noted.
A facility failed to maintain dignity and provide personal privacy for a resident by not covering the resident's catheter drainage bag, which was visible from the hallway. Despite the care plan's directive, the catheter bag was observed uncovered multiple times. Staff acknowledged the oversight and confirmed that the catheter should always be covered.
The facility failed to prevent a physical altercation between two residents, resulting in one resident being struck in the face with a cane and sustaining a skin tear. The incident occurred when one resident entered another's room, causing irritation and leading to the altercation. The facility's investigation confirmed the incident, and staff were instructed to monitor both residents for aggressive behavior.
A resident at risk for skin injury developed multiple open areas on the buttocks and thighs due to moisture and incontinence. The CNAs did not report these skin changes to the nurse, and the wound nurse was not informed until she conducted an assessment. The facility's wound treatment management policy was not followed, leading to a delay in appropriate wound care treatment.
The facility failed to provide consistent restorative services to two residents with limited mobility. One resident did not receive the required splint and range of motion exercises, while another did not have a knee splint applied for several weeks. Staff shortages and the reassignment of restorative aides contributed to the inconsistency.
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease, as there were no physician orders, dialysis provider information, or transportation details documented. Additionally, staff did not provide communication forms to the dialysis provider or assess the dialysis access site before or after treatment.
The facility failed to notify the attending physician about a pharmacy medication regimen review recommendation for a resident with diabetes, resulting in the omission of a recommended HgA1C test. Despite the facility's policy for frequent medication reconciliation, the necessary follow-up actions were not documented or completed.
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated for two residents receiving psychotropic medications. The necessary documentation for GDR was incomplete and unsigned by the physician, and no GDR attempts had been made, as confirmed by the Regional Nurse Consultant.
The facility failed to ensure accurate documentation and administration of medication for a resident. The LPN marked the MAR as if the medication was given, despite it not being available and not taken from the e-kit. Interviews revealed discrepancies in the medication administration process.
The facility failed to follow infection control practices during personal care for a resident requiring a Foley catheter and did not maintain proper hand hygiene during medication administration for another resident. An LPN reused a washcloth after rinsing it in the sink and handled medications with bare hands, contrary to the facility's policies.
A facility failed to provide a working call light system for a resident, preventing them from calling for assistance. The resident, who was dependent on assistance for daily activities, was observed yelling for help as the call light was not activated. Staff interviews revealed the call light system was unreliable, and the Maintenance Director did not conduct regular inspections, relying on staff to report issues.
The facility failed to post the Nurse Staffing Information daily as required. Observations revealed outdated or missing information, and the Regional Nurse Consultant was unable to provide current staffing details. The facility's policy mandates daily updates in a clear, accessible format, which was not followed.
The facility failed to provide an RN for eight consecutive hours per day, seven days a week, despite having a census of 90 residents. Staffing sheets for specific weekends showed only LPNs were present, with no RN coverage. The Administrator acknowledged the issue, noting the weekend RN was on leave.
A resident with severe cognitive impairment developed a pressure ulcer, but the facility failed to notify the responsible party as required by their policy. Despite documentation of the skin condition changes and new treatment orders by the Wound Nurse, there was no record of family notification, leading to a deficiency.
A resident in an LTC facility was physically abused by another resident who stabbed them in the face with a fork. The incident was unwitnessed by staff and occurred after a disagreement over a vending machine. The resident who committed the act was given an emergency discharge after making a threatening statement. Both residents had diagnoses of dementia, stroke, and depression, but no prior behaviors were noted.
Failure to Maintain Homelike Environment, Adequate Hot Water, and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by allowing excessively loud door alarms to sound repeatedly throughout the building, including during meal service, without timely staff response. During a dining observation with approximately 30 residents present, a fire exit door alarm sounded at a very loud volume and continued intermittently for several minutes before staff silenced it. Residents in the dining room reported that the alarms sounded constantly and were annoying. The Administrator acknowledged that the alarms had been sounding continuously since she began working at the facility months earlier, and that this was not homelike. The facility also failed to maintain adequate hot water temperatures in multiple resident rooms and bathing areas, affecting residents who were dependent on staff for bathing and personal hygiene. One cognitively intact resident with heart failure and hypertension reported not taking showers lately because the water was cold; observation showed no cold water from the cold tap and hot water measuring only 58.9°F after running for two minutes. Another cognitively intact resident with anxiety, depression, and PTSD stated the facility only had hot water sometimes; observation showed no cold water from the cold tap and hot water at 52.0°F after two minutes. A third cognitively intact resident with renal failure, neurogenic bladder, and paraplegia reported that the water in the room had not worked for several months and that the unit’s shower rooms did not have hot water; observation confirmed the sink water never became warm after several minutes. CNAs reported that some rooms had no hot water since the weather turned cold, that hot water was obtained from an eye wash station for resident care, and that residents on one unit were not receiving regular showers or bed baths due to cold water. Additionally, the facility failed to thoroughly clean one resident’s room and bathroom. Over multiple observations on different days, the perimeter of the room’s walls contained multiple small, dark pellet-like substances scattered along the floor and within crevices near the walls and furniture bases, along with accumulated dirt and debris. The bathroom toilet had visible brown staining and streaking on the exterior porcelain surface, with accumulated dirt and discoloration around the base where it met the flooring, and darkened residue and debris along the perimeter of the toilet base. The flooring immediately surrounding the toilet base was soiled and discolored. The resident reported that housekeeping staff entered and mopped briefly but did not perform a thorough cleaning.
Failure to Designate Grievance Official and Provide Accessible Grievance Process
Penalty
Summary
The deficiency involves the facility’s failure to implement its grievance policy by not identifying a grievance official responsible for overseeing the grievance process and not making grievance information and forms readily accessible. The written policy, dated 4/1/2022, specified that the facility would have grievance forms available 24/7 in an unsecured common area, notify residents via postings of their right to file grievances orally, in writing, and anonymously, and identify a Grievance Official (normally the Social Services Director) with name, business address, email, and phone number posted in prominent locations. The policy also stated that staff would assist individuals who could not or chose not to write, and that grievances noted verbally would be recorded on the facility’s grievance form or in the electronic tracking system. During a group interview with eight alert and oriented residents, all residents reported they did not know where grievance forms were located, and six did not know how to file a grievance even if a form were available. All eight residents stated they did not know who the Grievance Official was. The previous Grievance Official had been the Social Worker, but the facility did not have a Social Worker at the time, and six residents reported they did not know who else to go to with grievances or concerns. These resident reports demonstrated a lack of awareness of the grievance process and the designated grievance contact. Surveyor observations over multiple days showed that grievance forms were not readily accessible in unsecured common areas and that there was no visible information posted identifying the Grievance Officer, the location of forms, or how to file grievances orally, in writing, or anonymously. Grievance forms were found in the receptionist’s office, behind a desk in an unmarked folder, and were only provided upon request; the receptionist’s office was locked at night. The front desk staff stated that residents requesting to file a grievance were directed to the receptionist desk for a form and, if assistance was needed, were referred to the Social Worker, who was not employed at that time, and then to the HR office. The HR Manager reported that grievance forms were turned in to her because there was no Social Worker, that she sometimes sought help from the Activity Director, and that unresolved grievances were forwarded to the Administrator or DON. The HR Manager stated she did not know who was designated as the grievance officer and assumed it would be the Social Worker. The Administrator stated she expected signage identifying the Grievance Officer and freely accessible grievance forms, and that the process should allow anonymous grievances, confirming that these elements were not in place during the survey period.
Failure to Provide Bed-Hold Notices and Ombudsman Discharge Notifications
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents and/or their representatives with the required bed-hold policy information at the time of transfer to the hospital or as soon as practicable. Record review showed that between 9/1/25 and 2/2/26, 31 residents were transferred to acute care hospitals, yet the facility did not have documentation that the bed-hold policy had been provided for these transfers. During interview, the Administrator stated that floor nurses were responsible for giving the bed-hold policy at the time of transfer and acknowledged that the facility did not have the bed-hold documentation for residents who were transferred to the hospital. Surveyors also found that the facility failed to send copies of discharge notices to the Office of the State LTC Ombudsman as required by the facility’s own Transfer and Discharge policy dated 4/1/22. That policy required that a copy of the discharge notice be sent to the Ombudsman for 30-day facility-initiated discharges, planned discharges and transfers to the hospital initiated by the facility, and unplanned discharges where the facility decided to discharge the resident while hospitalized. Review of Ombudsman notifications showed the last notification was in July 2025, and the Ombudsman representative reported the last transfer log received was from August 2025. The facility also lacked copies of discharge notices after July 2025, despite 15 residents being discharged home and three discharged to another facility during the review period.
Failure to Provide Required Showers and Honor Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents who required assistance with activities of daily living received showers or baths in accordance with facility policy and resident preferences. The facility’s written policy required that showers or bathing be offered at least twice weekly or per resident/resident representative preference, with schedules developed for each resident and refusals reported to licensed staff. Surveyors requested a shower schedule but none was provided. For one resident with moderate cognitive impairment, impaired mobility, and a care plan specifying limited assistance with showering twice weekly, documentation showed only one shower or bed bath in October, two in November, one in December, and a refusal in January. Observations over several days showed this resident with long, messy, greasy hair, strong body odor, and wearing the same clothes, and the resident reported receiving showers only every two weeks or once a month, citing limited shower room availability and needing staff assistance to access the shower room. Another resident, cognitively intact with renal failure, neurogenic bladder, and paraplegia, required substantial/maximal assistance with bathing and had a care plan indicating a preference for a daily bed bath. Documentation for November and December showed four showers or bed baths each month, and two in January. However, this resident reported that the water in the room had not worked for several months and that shower rooms on the unit did not have hot water, resulting in not being offered showers or bed baths and an inability to recall the last shower. The resident stated a preference for daily shower or bed bath and described an instance when an aide declined to take the resident to another unit for a shower or obtain hot water from another unit, instead documenting a refusal after the resident’s request for hot water was not accommodated. A CNA confirmed that residents on the unit, including this resident, were not being showered regularly due to cold water and were not consistently receiving at least two showers or bed baths per week. A third cognitively intact resident, dependent on staff for bathing and personal care, reported not taking showers lately because the water was cold and instead performing partial “whore baths” at the sink. Review of shower sheets over nearly three months showed 19 opportunities, with only one documented shower, nine bed baths, and nine refusals. Facility leadership, including the DON, ADON, and Administrator, acknowledged that showers or bed baths were to be offered at least twice weekly and that resident choices, including daily bathing preferences, should have been honored. They also acknowledged that some residents may not have received showers or bed baths twice weekly due to inadequate water temperatures, despite the possibility of taking residents to other units for showers or obtaining hot water from other units.
Failure to Maintain Safe and Palatable Food Temperatures During Tray Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and drink were served at palatable, attractive, and safe temperatures during tray service. The facility’s own policy, revised 10/1/23, stated that food is to be cooked to specified temperatures and times to mitigate dangerous microorganisms and identified the danger zone for food temperatures as above 41°F and below 135°F. Multiple cognitively intact residents reported dissatisfaction with the food, including one resident with anemia, ulcerative colitis, Crohn’s disease, and inflammatory bowel disease who stated they barely ate the facility’s food and relied on their own snacks, another resident with heart failure and hypertension who said the food tasted bad, a resident with malnutrition who said the food was not good and often arrived cold, and a resident with renal disease and diabetes who said the food was sometimes served cold. Surveyor observations and temperature checks during meal service showed that hot foods were not consistently maintained at or above 120°F and that cold foods were not kept at appropriately cold or frozen temperatures. At one lunch service, lasagna on a tray from the 200 unit was lukewarm, initially 125°F but dropping to 112°F after 15 seconds, coleslaw measured 66°F and appeared wilted, and sherbet was melted. On the 100 unit at another lunch, salad with creamy dressing was warm at 76°F, lasagna was 102.6°F, and rainbow sherbet was mostly melted at 28.2°F. During an evening meal on the 100 unit, an LPN measured chicken bites at 95.4°F, corn at 109.9°F, and a fruit cup at 70.5°F. The Dietary Manager stated she expected food to be served at 135°F when it reached the resident and sherbet to be served frozen, and the Administrator stated she expected food to be served at a safe and appetizing level.
Failure to Follow Enhanced Barrier Precautions and Standard Infection Control Practices During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and standard precautions, during high-contact care for multiple residents. The facility’s EBP policy required an order for EBP for residents with chronic wounds, indwelling medical devices, or infection/colonization with certain MDROs, clear signage on the door indicating required PPE and high-contact activities, and the use of gown and gloves for high-contact care such as dressing, transferring, providing hygiene, changing linens, and changing briefs or assisting with toileting. The standard precautions policy required assuming every person could be infected or colonized and minimally handling contaminated laundry with appropriate PPE, placing it in leak-proof bags at the location of use. Surveyors observed that these policies were not followed for several residents. One resident with severe cognitive impairment, total dependence for toileting and personal hygiene, and diagnoses including stroke, multiple sclerosis, and altered mental status had an EBP sign and PPE at the room door. A CNA provided incontinence and peri-care without wearing a gown, contrary to the EBP requirement for high-contact care. During this care, the CNA cleaned the resident’s genital area from front to back abdomen (back to front), placed a soiled pad directly on the floor without a barrier, and moved blankets from the resident’s bed to the roommate’s bed and then back to the original resident’s bed. The Assistant DON later stated that peri-care for a female resident should be performed front to back, linens should not be transferred between residents’ beds due to cross contamination, and staff should wear a gown, gloves, and mask as needed for high-contact care. Another resident, cognitively intact but dependent for toileting and personal hygiene and always incontinent of bladder with frequent bowel incontinence, had a physician order for EBP for a chronic wound, with gown and gloves required for high-contact care. An EBP sign and PPE were present on the door. A CNA entered, performed hand hygiene, donned two pairs of gloves but no gown, and provided incontinence care, including cleaning the groin and between the legs. The CNA placed a soiled blanket on the floor without a barrier, used double gloving, and later used a folded blanket as a substitute for a pad, stating the facility had run out of pads. The CNA then picked up linens from the floor and placed them in a trash bag. The ADON stated staff should not double glove, should remove gloves and perform hand hygiene, and should not place soiled linens on the floor. A third resident with moderate cognitive impairment, dependence for toileting and personal hygiene, and diagnoses including stroke and hemiplegia/hemiparesis had an order for EBP for a chronic wound with gown and gloves required for high-contact care. This resident preferred to remain in bed and was totally dependent on staff for toileting and used incontinence products. A CNA provided peri-care while wearing gloves but did not wear a gown, despite the EBP order and high-contact nature of the care. A fourth resident, rarely or never understood, totally dependent for toileting and personal hygiene, always incontinent of bladder and bowel, and with diagnoses including cerebral palsy and gastrostomy status, had a care plan indicating EBP for a g-tube with gown and gloves required for high-contact care, but there was no corresponding physician order for EBP on the physician order sheet. An EBP sign and PPE were on the door, and a CNA provided peri-care wearing gloves but no gown. Additional staff interviews confirmed expectations that conflicted with observed practices. One CNA stated that residents requiring EBP were identified by a sign and PPE at the door and that staff should wear a gown, mask, face shield, and gloves every time they entered the room, remove PPE before exiting, avoid double gloving, place soiled linens in a trash bag rather than on the floor or another resident’s bed, and perform peri-care front to back. Another CNA similarly stated that peri-care should be front to back, staff should not double glove, and soiled linens should be placed in a linen cart or trash bag, and that staff should wear gown, gloves, and mask when providing close contact care to residents. The Administrator stated she expected staff to follow the facility’s infection control policies and procedures. These statements contrasted with the observed failures to use gowns during EBP-required high-contact care, improper handling of soiled linens, improper peri-care technique, and inconsistent implementation of EBP orders and signage.
Failure to Provide and Offer Bedtime Nourishing Snacks
Penalty
Summary
The facility failed to provide and offer nourishing bedtime snacks to residents in accordance with its own policy and resident needs and preferences. The facility’s undated Between Meal Snack/Bedtime Nourishments policy required that between-meal snacks and bedtime nourishments be offered to all residents unless contraindicated by a physician’s diet order, and specified that bedtime nourishment must consist of nourishing foods such as milk, 100% fruit juice, cookies, crackers, and fruit. The policy also stated that dietary should develop a snack nourishment stock level for each nursing station and that nursing staff were to pass snacks and nourishments from room to room, with an explicit statement that it was not acceptable to simply announce snacks from the nursing station. Surveyor review of Resident Council meeting minutes showed that residents had previously reported problems with snack availability and distribution. In one meeting, residents were told by a nurse that there were no snacks at the nurse’s desk, and in another, residents reported that dietary was not passing out snacks. During a group interview with eight alert and oriented residents, six reported they were not offered snacks at bedtime, and one reported that snacks were sometimes available at the nurse’s station for residents who could ambulate there, but staff did not come to resident rooms to offer snacks. Observations over several days showed no snacks at the nursing stations on three units. The Dietary Aide confirmed the scheduled meal times, and the Dietary Manager acknowledged that snacks had not been provided to nursing staff for delivery to residents. This deficiency affected all residents who ate at the facility, with a census of 83.
Failure to Maintain Clean, Pest-Free, and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple pest control and maintenance issues in resident rooms. In one instance, a resident with moderately impaired cognition, quadriplegia, and other significant health conditions was found in a room with multiple ants on the floor, in the sink, and on the wall by the sink. The resident's room also had a can of pesticide on the sink, a steadily dripping faucet, dust and debris around storage bins, and a black, fuzzy, wet, and spongy spot on the wall under the air conditioning unit, which transferred residue when touched. Staff interviews revealed a lack of awareness about the ant infestation and uncertainty about the timing of recent pest control visits. The maintenance log at the nurse's station was found to be empty, with no current work orders or requests documented at the time of review. Another resident, who had severely impaired cognition and required substantial assistance with daily activities, was found in a room with several small brown pellets on the floor behind the bed, identified by a family member as rat feces. Observations confirmed the presence of these droppings during multiple visits. Staff interviews indicated that pest control and maintenance issues were not consistently reported or addressed in a timely manner. The housekeeping manager acknowledged awareness of some issues, such as a leaking faucet, but was unaware of the extent of the pest problem and the water damage to the wall. The pest control company was reported to visit frequently, but the last visit could not be recalled. Review of facility policies and procedures for floor care outlined steps for cleaning and maintaining vinyl plank flooring, but observations indicated that these procedures were not being followed, particularly in high-traffic and problem areas. The maintenance log, intended for staff to report issues, was not being utilized effectively, and completed and incomplete work orders were not readily available for review. Interviews with nursing and housekeeping leadership confirmed that cleaning and pest control should be prioritized, but acknowledged delays and lapses in reporting and addressing these deficiencies.
Failure to Timely Process and Administer Ordered Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when staff did not process an ordered narcotic pain medication, Tramadol 50 mg, in a timely manner for a resident with moderate cognitive impairment and heel wounds. The resident was re-admitted with a care plan indicating a risk for pain related to stroke, and interventions included administering pain medication as ordered. Despite a physician order for Tramadol to be given twice daily, the medication was not delivered promptly by the pharmacy, and staff did not promptly contact the physician to ensure the prescription was processed. Documentation in the medical record and Medication Administration Record (MAR) showed that the resident missed a total of six doses of Tramadol over several days. Progress notes indicated that the medication was unavailable and that the pharmacy was waiting for a signed prescription. Staff administered acetaminophen as needed in place of the ordered Tramadol. The facility's emergency stock (e-kit) contained Tramadol, but staff were unable to access it because the pharmacy required a signed prescription before providing the access code. Interviews with staff revealed that the nurse practitioner (NP) who wrote the order did not have a DEA number, which prevented the pharmacy from filling the prescription. The process for obtaining the necessary prescription signatures was not clearly defined, and staff did not have a protocol to ensure timely processing of narcotic orders. The Director of Nursing confirmed that the resident did not receive any Tramadol until several days after the order was written, and that staff had documented administration of the medication when it was not actually available.
Failure to Maintain Adequate Hot Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain appropriate water temperatures throughout multiple resident areas, including hallway shower rooms and individual resident rooms. Observations with a calibrated digital thermometer revealed that hot water temperatures in various sinks and shower stalls ranged from 72.4°F to 97.1°F, which is below typical standards for hot water in such settings. Several rooms and shower areas consistently provided water that was not sufficiently warm, and in some cases, shower stalls lacked proper fixtures such as showerheads. The facility's water temperature policy did not specify recommended temperature parameters, and there was no evidence of regular monitoring or documentation of water temperatures. Interviews with staff, including CNAs and the Maintenance Director, indicated ongoing issues with water temperature, with some staff reporting that residents had complained about the lack of hot water for several months. Staff described having to take extra steps, such as running water for extended periods or transporting warm water in bags, to accommodate residents' needs for bathing and personal care. Some staff noted that only a few rooms had access to warm water, and that the problem had persisted for an extended period, affecting both residents who required assistance and those who bathed themselves. Administrative staff, including the Administrator and DON, were not fully aware of the extent of the water temperature issues or the specifics of the facility's water temperature policy. The Maintenance Director was unable to locate maintenance or water temperature logs, and there was confusion regarding policy documentation due to changes in facility ownership and staff turnover. The lack of clear policy parameters, regular monitoring, and documentation contributed to the ongoing deficiency in providing a safe, comfortable, and homelike environment for residents.
Failure to Monitor Water Temperatures and Incomplete Fall Investigation
Penalty
Summary
The facility failed to monitor and maintain safe water temperatures throughout the building, resulting in hot water in two resident rooms measuring significantly above the required range, with temperatures recorded at 136.5°F and 141.0°F. The maintenance director, who was new to the position, was unable to locate any water temperature logs or maintenance records, and there was no clear policy in place specifying acceptable water temperature parameters. Interviews with staff and residents confirmed that the water in these rooms was very hot, and the maintenance director acknowledged that water temperature checks had not been performed as required. Additionally, the facility did not conduct a complete and thorough investigation following a resident fall. One resident, who was moderately cognitively impaired and had a history of falls, experienced an unwitnessed fall and was subsequently sent to the emergency room for evaluation. Documentation related to the incident was incomplete, as the facility was unable to provide witness statements or neurological check records for the resident. The care plan for this resident indicated multiple previous falls, but no new interventions were added after the most recent incident, and required post-fall assessments and documentation were not completed. Interviews with facility leadership, including the administrator and DON, revealed that they did not have access to the previous company's policies and procedures, including those related to water temperature monitoring and fall investigations. The DON stated that a full and thorough investigation should be completed after every fall, including head-to-toe assessments, pain evaluations, and neuro checks, but these were not documented for the resident in question. The lack of policies, procedures, and documentation contributed to the deficiencies identified during the survey.
Failure to Protect Resident Confidentiality and Secure Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records in multiple ways. Identifying information, including a medication card with the resident's name, room number, medication name, and dose, was observed sticking out of an unlocked shred bin located in an area accessible to residents, staff, and the public. The shred bin was not locked, and the area was not secured, allowing anyone to access confidential information. Additional observations revealed that other shred bins in the facility were also full, overflowing, and located in unsecured areas, with confidential resident information visible and accessible. Staff practices further compromised resident confidentiality. An LPN, lacking access to the facility's e-fax system and a work email, used a personal device to take a photo of a resident's medication prescription and then sent it to the pharmacy using a personal email address. This process exposed the resident's name, date of birth, and prescription details. Interviews with facility staff and management confirmed that floor nurses did not have access to secure communication methods for transmitting sensitive information, and there was confusion about proper procedures for sending prescriptions to the pharmacy. The facility did not have a current policy on maintaining the confidentiality of resident medical records available when requested. The administrator and DON acknowledged that the use of personal devices and unsecured email for transmitting resident information, as well as the exposure of confidential documents in unlocked and overflowing shred bins, constituted privacy violations. The facility was also in the process of changing shred companies, and there was uncertainty about when confidential materials were last securely disposed of.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving one resident who was slapped by another resident. According to the facility's policy, any suspicion or allegation of abuse must be immediately reported to the charge nurse, who is then responsible for notifying the Administrator or Director of Nursing and making the required notifications to state authorities. In this case, documentation showed that a restorative aide informed a nurse that a resident had slapped their roommate. The incident was acknowledged by the resident who was slapped, and the Director of Nursing was notified. The involved residents were separated, and one was sent for psychiatric evaluation. Despite these actions, there was no documentation of a formal investigation or a report being made to the Missouri Department of Health and Senior Services (DHSS) as required by policy. Staff interviews revealed uncertainty about whether the incident was reported to authorities. The Social Services Director and Human Resources Manager both stated they had no direct knowledge of the notification being sent, and there was no evidence or confirmation of a report being filed. The previous Administrator, who was terminated, claimed to have reported the incident but left no documentation or investigation records. The lack of documentation and confirmation of reporting the abuse incident constitutes a failure to follow the facility's abuse investigation and reporting policy. The incident involved residents with significant medical and psychiatric histories, including schizophrenia and stroke-related disabilities. The absence of a documented investigation and notification to authorities represents a deficiency in the facility's response to suspected abuse.
Failure to Investigate Alleged Misappropriation and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations: one involving misappropriation of property (narcotics) by an LPN, and another involving resident-to-resident physical abuse between two residents. In the case of the alleged misappropriation, the facility's records lacked documentation of a statement from the accused LPN, resident interviews, staff interviews, a summary or conclusion of the incident, or any witness statements. The initial allegation was made by the LPN's significant other, who claimed the LPN possessed prescription bottles and medication cards without names, and the facility administrator notified the police and state authorities. However, there was no evidence that a comprehensive investigation was conducted, as required by facility policy. For the resident-to-resident abuse allegation, the facility failed to document a thorough investigation into an altercation between two residents. The care plans and progress notes indicated a history of physical altercations and behavioral issues, but there was no documentation of a completed investigation, witness interviews, or a summary of findings. Staff interviews revealed that the previous administrator claimed to have notified the state, but there was no confirmation or supporting documentation. Staff members were generally unaware of the details of the incident, and the file related to the incident was found empty after the administrator's departure. Both deficiencies were compounded by a lack of proper documentation and follow-through on required investigative steps, as outlined in the facility's own policies. The absence of statements, interviews, and investigative summaries for both the misappropriation and abuse allegations demonstrates a failure to respond appropriately to alleged violations, as required by federal and state regulations.
Failure to Provide Consistent Wound Care and Assessments Resulting in Maggot Infestation
Penalty
Summary
The facility failed to ensure that weekly wound assessments and ordered wound treatments were performed as prescribed for a resident with multiple complex medical conditions, including paraplegia, severe malnutrition, and several pressure ulcers. Documentation revealed that wound care orders, such as the application of Collagenase Ointment and Vashe Wound Solution, were not consistently signed out or completed as required, with numerous missed opportunities recorded on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Only two weekly wound assessments were documented for the entire month of August, despite expectations for weekly assessments. The lack of consistent wound care and assessment was confirmed by staff interviews, with nurses and the DON acknowledging that if treatments were not signed out on the TAR, they were not done. A significant event occurred when a resident was found with small, white, legless, worm-like organisms (maggots) in their wound and brief during a routine care episode. The CNA and nurse responded by cleaning the wound, changing the dressing, and cleaning the resident and their environment. The resident reported that staff did not change dressings daily as ordered and expressed embarrassment about the incident. Staff interviews confirmed the presence of maggots and noted environmental factors such as food crumbs and flies in the resident's room. The incident was not reported to all relevant nursing staff, and no investigation was initiated by facility leadership. Additionally, the facility did not have wound care or pressure ulcer policies and procedures available to staff. The DON and Administrator both stated they did not have access to such policies, and the DON had not been provided with any. The absence of these policies, combined with the lack of a designated wound nurse and inconsistent documentation and performance of wound care, contributed to the deficiency. The failure to provide appropriate pressure ulcer care and prevent new ulcers had the potential to affect all residents with wounds in the facility.
Failure to Promote Resident Self-Determination and Provide Adequate Care
Penalty
Summary
The facility failed to promote and facilitate self-determination for residents dependent on staff for transfer assistance by not ensuring residents were out of bed daily according to their preferences. Resident #71, who had no cognitive impairment and required extensive assistance for mobility and personal hygiene, reported being out of bed only twice since admission. Multiple observations confirmed the resident remained in bed despite expressing a desire to get up. Staff interviews revealed that the facility was often short-staffed, which hindered their ability to assist residents in getting out of bed as per their preferences. Additionally, the facility did not provide showers or baths according to resident preferences. During a group meeting, five alert and oriented residents reported not being offered at least two showers per week and being told it was not their shower day when they requested one. One resident, who required a mechanical lift for transfers, stated they were often unable to get out of bed due to staff shortages. Staff interviews corroborated that residents did not always receive the required number of showers per week and were not always able to get out of bed daily due to insufficient staffing. The facility's policy on Resident Rights emphasized the importance of promoting self-determination and accommodating resident preferences. However, interviews with the Director of Rehab, LPNs, CNAs, and the Regional Nurse Consultant indicated that the facility's staffing issues frequently prevented them from meeting these standards. The Administrator, DON, and RNC acknowledged that residents should receive at least two showers per week and be up and out of bed daily, but this was not consistently achieved due to staffing constraints.
Facility Fails to Maintain Functional Equipment and Safe Environment
Penalty
Summary
The facility failed to ensure a functional bathroom toilet for one resident, resulting in the resident having to use a shower room down the hallway for four out of five days of the survey. The resident reported the issue to staff, but the toilet remained clogged with a dark brown substance and toilet paper floating on the surface. Additionally, the facility failed to ensure functional bathroom lights and comfortable water sink temperature and pressure for two other residents, with one resident's bathroom light not working and the water temperature being consistently cold at 77.5 degrees Fahrenheit. Another resident experienced low water pressure in their sink, causing a very small stream of water to come from the faucet. The facility also failed to ensure a functional call light for one resident, who repeatedly yelled for help but received no response due to the call light not being activated. The resident reported the issue, and a CNA confirmed that the call lights were unreliable. The Maintenance Director admitted to not conducting regular equipment inspections and was unaware of the clogged toilet and other issues. He relied on staff to report broken equipment through a maintenance log binder, which he checked multiple times a week. The Regional Nurse Consultant expected resident room lights to be in working condition and water temperatures to be appropriate. The Maintenance Director was expected to keep a maintenance log to inspect and maintain all resident rooms and patient care equipment in functional condition. However, the lack of regular inspections and immediate repairs led to multiple deficiencies in the facility's environment, impacting the residents' safety, comfort, and dignity.
Failure to Provide Adequate Shower Care
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living (ADL) care received showers in accordance with their personal needs. Eight residents were identified as not receiving showers as per the facility's policy. The facility's Resident Showers Policy mandates that residents be provided showers as per request or facility schedule protocols, and partial baths may be given between regular showers. However, observations and interviews revealed that residents were not receiving the required three showers per week due to staffing issues, and there were no shower sheets available for documentation. Resident #19, who had severe cognitive impairment and was dependent on staff for ADLs, was observed multiple times with dirty and long nails, disheveled hair, and a strong urine odor. The resident's fitted sheet had dried blood stains, and the incontinence brief was wet and soiled. Despite these conditions, the resident had not received a shower recently, and staff failed to provide timely care. Similar observations were made for Resident #17, who was cognitively intact but required substantial assistance with ADLs. The resident had long and dirty nails and emitted a strong scent of urine, indicating a lack of proper hygiene care. Other residents, including Resident #15, Resident #51, Resident #35, Resident #78, Resident #39, and Resident #50, also reported not receiving showers for several weeks. These residents expressed their desire for showers and dissatisfaction with the bed baths or wipe-downs provided by the staff. The Regional Nurse Consultant (RNC) confirmed the lack of shower sheets for these residents, further highlighting the facility's failure to adhere to its shower policy. The Administrator and RNC acknowledged that each resident should receive a shower twice a week and that bed baths with wipes are not considered adequate substitutes for showers.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure proper bed rail assessments and fall interventions for a resident, leading to multiple falls and injuries. Resident #71, who was cognitively intact and required full staff care for ADLs, experienced several falls due to inadequate bed rail maintenance and insufficient staff assistance. Despite having a physician's order for bed rails, the resident's bed rail was broken and not repaired, resulting in the resident falling out of bed multiple times. Additionally, the facility was frequently short-staffed, which contributed to the lack of timely assistance and supervision for the resident, further exacerbating the risk of falls and injuries. The facility also failed to ensure safe mechanical lift transfers for three residents. Observations revealed that staff did not follow the policy requiring two staff members to assist with mechanical lift transfers. In several instances, residents were left suspended in the air without proper support, and the mechanical lift equipment was not inspected for functionality before use. This negligence in following safe transfer protocols put the residents at risk of injury during transfers. Furthermore, the facility did not complete smoking assessments for two residents, allowing them to keep smoking materials in their rooms unsupervised. This was against the facility's policy, which required smoking materials to be stored by nursing staff and only provided to residents as needed. Additionally, staff failed to respond promptly to an exit door alarm, which had been malfunctioning for a month. The lack of timely response and proper headcount procedures during the alarm further highlighted the facility's inadequate supervision and safety measures for residents at risk of elopement.
Inadequate Staffing Leading to Deficient Resident Care
Penalty
Summary
The facility failed to maintain appropriate and competent staffing to adequately provide resident care and meet resident needs. This deficiency was observed through various instances involving multiple residents. For example, Resident #71, who required extensive assistance for bed mobility and personal hygiene, was observed being repositioned in bed by a single CNA, contrary to the care plan that required two staff members. The resident and their family expressed concerns about insufficient staffing and lack of timely assistance, including an incident where the resident fell out of bed and had to rely on a family member to get help before staff arrived. Additionally, the facility was noted to be short-staffed, with one LPN covering multiple halls and having to find additional staff to assist with mechanical lifts, further indicating inadequate staffing levels to meet resident needs effectively. Resident #39, who required moderate assistance with bathing, reported not having had a shower for over a month due to staff shortages. The resident's hair appeared unkempt, and staff confirmed that there were not enough personnel to provide showers regularly. Similarly, Resident #50, who also required moderate assistance with bathing, had not received a shower in over a month and was only given wipe-downs with wet wipes or washcloths due to the lack of staff. These observations highlight the facility's failure to provide basic hygiene care as per the residents' needs and care plans. Resident #19, who was severely cognitively impaired and dependent on staff for ADLs, was found in an unkempt state, emitting a scent of urine, and had not received a shower recently. The CNA responsible for the resident confirmed that residents were not receiving the scheduled three showers per week due to staffing issues. The Regional Nursing Consultant acknowledged the expectation for two staff to provide care for residents requiring it and for showers to be given as scheduled. However, the facility's staffing levels were insufficient to meet these expectations, leading to the observed deficiencies in resident care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. During observations, multiple medication carts and a medication room were found with opened, undated, and expired over-the-counter (OTC) medications. Additionally, a refrigerator storing unopened insulin pens was found unsteady and leaning sideways, with a thermometer stuck in the freezer and no temperature log sheet observed. The facility's Medication Storage Policy mandates proper labeling, storage, and temperature control of medications, which was not adhered to in these instances. On Hall 300, opened OTC medication bottles were found with expired dates, and some were undated. Similar issues were observed on Hall 100, where multiple opened OTC medication bottles were also expired or undated. The treatment cart on Hall 400-500 contained opened tubes of medications that were either expired or undated. Additionally, the medication cart on Hall 400-500 had multiple opened OTC medication bottles that were undated but within the current expiration date. Interviews with staff revealed inconsistencies in maintaining and organizing medication carts and rooms. A Certified Medication Technician (CMT) admitted to using undated medications as long as they were not expired and acknowledged the lack of consistency due to staff changes. The Assistant Director of Nursing (ADON) confirmed that the night shift nurse was responsible for maintaining the refrigerator temperature record, which was missing in the Hall 400-500 medication room. The Regional Nurse Consultant expected staff to date medications when opened and check expiration dates before administration, which was not consistently practiced.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain dignity and provide personal privacy for a resident when staff did not place a cover over the resident's half-full catheter drainage bag, which was visible from the hallway through the resident's open room door. This deficiency was observed multiple times over several days. The resident, who was cognitively intact and used a wheelchair, had a suprapubic catheter due to a neurogenic bladder and required dependent assistance for toileting hygiene. The resident's care plan specifically included an intervention to ensure the catheter bag was covered to maintain the resident's dignity. Despite the care plan's directive, observations on four separate occasions showed the catheter bag was not covered. Interviews with multiple Licensed Practical Nurses (LPNs) and the Regional Nursing Consultant confirmed that the catheter should have been covered and that staff were expected to follow the resident's care plan. The failure to cover the catheter bag was acknowledged by the staff, who admitted that the catheter should always be covered to respect the resident's dignity and privacy.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse was not violated when two residents were involved in a physical altercation. Resident #3, who has severe cognitive impairment and uses a wheelchair independently, was struck in the face with a cane by Resident #76, resulting in a skin tear to the forehead. Resident #76, who has moderate cognitive impairment and ambulates independently, admitted to twirling the cane when Resident #3 got too close, leading to the injury. The incident occurred when Resident #3 entered Resident #76's room, causing irritation to Resident #76, who then struck Resident #3 with the cane. The facility's investigation revealed that the charge nurse observed Resident #3 with blood on the forehead and immediately separated the residents. The physician, Administrator, resident representatives, and DON were notified, and both residents were sent to the emergency room for evaluation. Resident #3's hospital visit summary showed no intracranial injury. Interviews with staff indicated that Resident #76 had a history of verbal aggression, but there were no prior conflicts between the two residents. The Social Services Director confirmed that staff were instructed to monitor both residents for aggressive behavior following the incident. The facility's policy on abuse, neglect, and exploitation mandates the protection of residents from all types of abuse and requires immediate intervention in situations where abuse is likely to occur. Despite these policies, the facility failed to prevent the altercation between the two residents, resulting in physical harm to Resident #3. The incident was substantiated, and the facility's response included monitoring both residents and updating their care plans to prevent future occurrences.
Failure to Report and Address Skin Impairment
Penalty
Summary
The facility failed to ensure a resident at risk for skin injury did not develop skin impairment. The staff did not report the skin impairment to the nurse when it was discovered. The resident, who had multiple diagnoses including diabetes, asthma, and morbid obesity, was found to have open areas on the buttocks and thighs due to moisture and incontinence. Despite having orders for barrier cream and wound consults, the resident's skin issues were not documented or reported in a timely manner. During observations and interviews, it was revealed that the resident had open areas on the buttocks and thighs, which were not reported to the nurse by the CNAs. The wound nurse, who had been in the position for two weeks, was not informed of the resident's skin issues until she conducted an assessment. The resident's skin condition included multiple areas of shearing and a Stage II wound with serosanguineous drainage. Additionally, the resident had an ingrown toenail that was not previously addressed. The facility's wound treatment management policy required that wound treatments be provided according to physician orders and that any changes in skin condition be reported immediately to the nurse. However, the CNAs did not report the resident's skin changes, and the weekly skin assessments did not reflect the resident's current condition. The LPN confirmed that aides are expected to report changes immediately, but this protocol was not followed, leading to a delay in appropriate wound care treatment for the resident.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two residents. Resident #19 had an order for occupational therapy to evaluate and treat a right-hand splint, but there was no documentation of restorative services being provided. Observations showed the resident lying in bed with a contracted right hand and no splint. Interviews with CNAs revealed that the resident was supposed to receive restorative services daily, but these services were not consistently provided due to staff being pulled to the floor to provide care. The resident confirmed that the splint was applied for the first time during the survey period. Resident #35 had contractures to both upper and lower limbs and was supposed to receive restorative therapy, including the application of a right knee extension splint. However, observations and interviews indicated that the resident had not received any restorative therapy for several weeks, and the splint had not been applied. The resident confirmed the lack of restorative services, and staff interviews corroborated that restorative aides were often reassigned to other duties due to staffing shortages. Interviews with the Director of Rehabilitation, the Regional Nurse Consultant, the Director of Nursing, and the Administrator confirmed that the facility's restorative nursing program was inconsistent. The facility had not had a stable Director of Nursing for several months, and the restorative aides were frequently pulled to work the floor, preventing them from providing consistent restorative services. The facility acknowledged the deficiency in their restorative nursing program.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident who received routine dialysis treatment had physician orders in place and consistent communication with the dialysis provider. The resident, who was cognitively intact and had diagnoses including heart failure, end-stage renal disease, and lung disease, did not have dialysis orders, dialysis provider information, or transportation details documented in the Physician Order Sheet. Additionally, the facility staff did not provide communication forms to the dialysis provider and did not assess the dialysis access site before or after treatment, as confirmed by the resident and the Regional Nurse Consultant. The facility's hemodialysis policy required ongoing assessment of the resident's condition, communication with the dialysis provider, and documentation of dialysis treatments and physician orders. However, these requirements were not met for the resident, as there were no dialysis communication forms in the medical record, and the dialysis orders were missed on the POS. The Regional Nurse Consultant acknowledged that the resident was admitted after an audit and that the dialysis orders were overlooked. The Charge Nurse was expected to catch the missing dialysis order, and communication forms should have been sent with and returned with the resident following each treatment.
Failure to Notify Physician of Pharmacy Recommendations
Penalty
Summary
The facility failed to notify the attending physician about the pharmacy medication regimen review recommendation for a resident. The resident, who had no cognitive impairment and was diagnosed with depression, anxiety disorder, and paraplegia, was on a regimen that included Novolin N FlexPen and Humalog KwikPen for diabetes management. The pharmacy review recommended a HgA1C test for baseline and subsequent monitoring every six months due to insulin therapy. However, there was no documentation in the resident's medical record indicating that the physician was notified of this recommendation, nor was the HgA1C test completed. The facility's Medication Reconciliation policy mandates frequent medication reconciliation to ensure residents are free from significant medication errors and that the facility's medication error rate remains below 5 percent. Despite this policy, the review of the resident's progress notes and medical records showed a lack of follow-through on the pharmacy's recommendations. During an interview, the Regional Nursing Consultant confirmed that nursing staff are expected to notify the physician of any pharmacy medication regimen review recommendations and follow any subsequent orders, which did not occur in this case.
Failure to Document or Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated for two residents receiving psychotropic medications. Resident #19 had an order for Sertraline, an antidepressant, but there was no documentation indicating an attempt to reduce the dose or a justification for not doing so. The resident's care plan included the use of antidepressant medication for depression, but the necessary documentation for GDR was incomplete and unsigned by the physician. Similarly, Resident #17 had an order for Quetiapine, an antipsychotic, but the required documentation for GDR was also incomplete and unsigned. The resident's care plan included the use of psychotropic medications, but there was no follow-up on the GDR as expected. During an interview, the Regional Nurse Consultant confirmed that no GDR attempts had been made for these residents. The facility had recently hired a new Director of Nursing, who started shortly before the survey. The consultant expected that GDR should have been followed up on, but it was not done for these residents. The facility's failure to document or attempt GDR for these residents receiving psychotropic medications constitutes a deficiency in care.
Failure to Accurately Document and Administer Medication
Penalty
Summary
The facility failed to ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff documented the administration of a medication for a resident, despite the medication not being available. The resident, who was cognitively intact and had multiple diagnoses including anemia, high blood pressure, ulcerative colitis, kidney disease, diabetes, high cholesterol, stroke, seizures, and depression, was prescribed Linzess to be taken orally every Monday, Wednesday, and Friday for constipation. On the observed date, the medication was not found on the medication cart, and the LPN indicated they would reorder it from the pharmacy. However, the LPN later claimed the medication was taken from the facility's emergency kit, which was not accurate as the medication was not listed in the e-kit inventory. Despite this, the MAR was marked as if the medication had been administered at the scheduled time. Interviews with the LPN, pharmacist, ADON, and RNC revealed discrepancies in the medication administration process. The pharmacist confirmed that the medication was refilled later that night and was not part of the e-kit. The ADON and RNC both stated that if the MAR was initialed, it indicated that the medication was given, which was not the case here. This failure to accurately document and administer medication as per the facility's protocol and professional standards led to the identified deficiency.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to follow acceptable infection control practices during personal care for a resident who required a Foley catheter insertion. The Licensed Practical Nurse (LPN) used a washcloth to clean the resident's groin area but rinsed the washcloth in the sink and reused it multiple times, which is against the facility's infection control policy. The resident had a history of irregular heartbeat, diabetes, stroke, and one-sided paralysis, and required full hygiene care from the staff. The LPN acknowledged that a fresh washcloth should have been used instead of rinsing and reusing the same one in the sink. Additionally, the facility failed to maintain proper hand hygiene during medication administration for another resident. An LPN handled medications with bare hands and did not sanitize their hands before or after touching the medications. The LPN also picked up spilled tablets from the medication cart with bare hands and returned them to the container, which is against the facility's medication administration policy. The resident involved was cognitively impaired and had multiple diagnoses, including heart failure, high blood pressure, diabetes, Alzheimer's disease, and asthma. Interviews with staff, including the Regional Nurse Consultant, confirmed that the actions observed were not in compliance with the facility's infection control and medication administration policies. The staff acknowledged that washcloths should not be rinsed and reused, and spilled or dropped medications should be destroyed and replaced, not touched with bare hands. The facility's policies clearly outline the importance of hand hygiene and proper handling of medications to prevent contamination and infection.
Failure to Provide Working Call Light System
Penalty
Summary
The facility failed to provide a working call light system for a resident, which prevented the resident from calling for staff assistance. The resident, who had no cognitive impairment and was dependent on assistance for activities of daily living, was observed yelling for help because the call light was not activated. The resident's care plan emphasized the need for the call light to be within reach and for prompt response to requests for assistance. However, the call light system was found to be non-functional during the surveyor's observation. Interviews with staff revealed that the call light system was unreliable, with some lights not working properly. The Maintenance Director admitted to not conducting regular equipment inspections and relied on staff to report broken equipment through a maintenance log binder. The Regional Nursing Consultant expected the call lights to be functional and for the Maintenance Director to maintain a log and inspect the call lights regularly. The facility's policies required a safe and functional environment, including a working nurse call system in resident rooms and toilet/bathing facilities, which was not upheld in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Nurse Staffing Information on a daily basis as required by their policy. Observations on two separate dates revealed that the Nurse Staffing Information was either outdated or missing entirely. On 4/15/24, the posted information was dated 4/8 and 4/10, and it was placed in a location that was not easily accessible, being approximately 6 feet or higher from the ground. On 4/18/24, no Nurse Staffing Information was posted at the same location where it was previously observed. During an interview on 4/18/24, the Regional Nurse Consultant (RNC) stated that the Nurse Staffing Information was supposed to be updated and posted according to the facility's policy. However, the RNC was unable to show or provide the current information. The facility's policy mandates that the Daily Staffing Sheet should be posted at the beginning of each shift in a clear and readable format, in a prominent place readily accessible to residents and visitors, and should reflect any staff absences due to callouts and illness. The failure to adhere to this policy led to the deficiency noted in the report.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, despite maintaining a census of greater than 60 residents, specifically 90 residents. This deficiency was identified through a review of the facility's staffing sheets for specific weekends, including 11/19/23, 11/20/23, 11/25/23, 11/26/23, and 12/3/23, which showed that only Licensed Practical Nurses (LPNs) were staffed, with no RN present on these days. During an interview on 12/19/23, the Administrator acknowledged the lack of RN coverage on weekends, attributing it to the weekend RN being on leave, which she realized upon returning from vacation. This oversight had the potential to affect all residents in the facility.
Failure to Notify Responsible Party of Pressure Ulcer Development
Penalty
Summary
The facility failed to notify a resident's responsible party after the development of a pressure ulcer. The resident, who had severe cognitive impairment and required total assistance for all activities of daily living, was at risk for skin integrity issues due to impaired mobility, incontinence, and other health conditions. Despite the facility's policy on pressure injury prevention and management, which included notifying the responsible party of any new skin breakdown, there was no documentation showing that the responsible party was informed of the changes in the resident's skin condition. The resident's progress notes indicated the development of a pressure ulcer and subsequent changes in skin condition, including moisture-associated skin dermatitis with eschar tissue. The Wound Nurse documented these changes and obtained new treatment orders, but failed to notify the responsible party. Interviews with facility staff, including the Wound Nurse and Director of Nurses, confirmed that it was the Wound Nurse's responsibility to notify the family of such changes, yet this was not done, leading to the deficiency.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse, as evidenced by an incident involving two residents. On November 30, 2023, one resident stabbed another in the face with a fork in the common area/dining room. The altercation was unwitnessed by staff, and the incident was reported to local authorities and the state entity. The resident who was attacked had a history of stroke, dementia, and depression, with cognitive impairment but no prior behaviors noted. The resident who committed the act had diagnoses of dementia, stroke, and depression, with no cognitive impairment or prior behaviors noted. The incident occurred when the resident who committed the act felt disrespected after the other resident was in front of a vending machine and refused to move. This led to the resident pulling a fork from their pocket and striking the other resident in the face. The altercation resulted in a small scratch on the victim's left cheek, and the resident who committed the act was given an emergency discharge after expressing a threat to kill the other resident. Interviews with staff and residents revealed that there were no known prior issues between the two residents involved in the altercation. The Director of Nurses and the Administrator both expressed surprise at the incident, as both residents were generally friendly and got along with others. The facility's abuse prevention policy outlines the commitment to protecting residents from abuse and the procedures for reporting and investigating such incidents.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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