Aspire Senior Living Platte City
Inspection history, citations, penalties and survey trends for this long-term care facility in Platte City, Missouri.
- Location
- 220 O'rourke Drive, Platte City, Missouri 64079
- CMS Provider Number
- 265696
- Inspections on file
- 27
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Aspire Senior Living Platte City during CMS and state inspections, most recent first.
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.
Staff were observed being unnecessarily rough while providing care to two residents, failing to honor their rights to dignity and respect. This deficiency was identified through observation, interview, and record review.
A resident sustained an open fracture to the right femur, and the DON assessed the injury but did not report it to DHSS or immediately notify the Administrator. This failure to report an injury of unknown origin was identified through interviews and record review.
A resident sustained an open fracture to the right femur, and the DON assessed the injury but did not initiate an investigation to determine its cause. This failure to respond appropriately to an alleged violation was identified through interview and record review.
A CMT verbally abused a resident with multiple health conditions by yelling derogatory terms related to the resident's body type and abilities, and physically pushed the resident's wheelchair aggressively after the resident did not move as instructed. The incident was witnessed by a staff member and later admitted by the CMT, despite recent training on abuse prevention.
Staff did not report an injury of unknown origin after becoming aware that a resident had a right leg femur fracture. The incident was not reported as required, and continued non-compliance was identified during a revisit.
A resident sustained a femur fracture of unknown origin, and the facility did not complete a thorough investigation or maintain documentation to show that the alleged violation was fully investigated.
Two residents were subjected to rough and undignified care during personal hygiene assistance, including being handled forcefully and without proper communication. Staff interviews and direct observation confirmed that care was provided in a hurried and rough manner, with one CNA scrubbing a resident's perineal area vigorously and failing to explain the procedure. These actions did not align with facility policies requiring gentle, respectful, and person-centered care.
A resident with dementia and a history of physical aggression was observed by staff with their hand down the front of another resident's pants, constituting non-consensual sexual contact. The incident was witnessed by another resident and reported to staff, who intervened. Both residents involved had severely impaired cognitive skills and complex medical histories, and neither recalled the incident during interviews.
A resident with severe cognitive impairment and quadriplegia was found to have a right femur fracture of unknown origin. Despite facility policy requiring immediate reporting of such injuries, the DON and Administrator did not notify authorities within the required timeframe, instead waiting for additional information from the hospital and corporate office. Staff interviews confirmed no known cause for the injury, and the event was not reported as mandated.
A resident with severe cognitive and physical impairments sustained a femur fracture of unknown origin. The facility did not conduct a thorough investigation or maintain adequate documentation as required by policy, relying only on brief verbal staff interviews without written statements or detailed records. The incident followed a prior mechanical lift event, but the investigation failed to identify all involved staff or fully explore the cause of the injury.
The facility failed to update and follow the code status of two residents as directed by their guardians. One resident's guardian requested a DNR status, but the facility did not update the records, leading to unwanted CPR. Another resident's guardian also requested a DNR status, but the facility failed to document the change. Staff interviews revealed communication lapses and unclear responsibilities in handling code status updates.
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported receiving cold, unappetizing food, and staff interviews confirmed ongoing issues with maintaining food temperatures, particularly for room trays.
The facility failed to adhere to professional standards of food service safety, including improper use of beard coverings, inadequate hand hygiene, failure to label and date food items, and poor kitchen cleanliness. Staff did not consistently follow protocols, and the facility lacked systematic approaches to ensure food safety and sanitation.
The facility failed to treat residents with respect and dignity by not knocking on doors before entering, leaving doors open during peri-care, and not responding to call lights in a timely manner. These actions affected four residents, leading to exposure and incontinence issues.
The facility failed to respect and facilitate the rights of two residents to go outside unsupervised, despite their cognitive ability and expressed preferences. Staff confirmed that residents were required to be supervised while outside due to safety concerns and staff availability.
The facility failed to maintain a sufficient surety bond to protect resident funds. The average monthly balance of resident funds was $27,000.00, but the facility only had a $1,000.00 bond, making it insufficient by $22,000.00. The Business Office Manager admitted that the bond had not been reassessed since a recent change in ownership.
The facility failed to protect resident rights by not providing accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency. Residents were unaware of what an ombudsman was, where the information was posted, or how to reach the ombudsman. The Administrator confirmed the information was posted but did not know how residents had been educated on accessing it.
The facility failed to clarify the code status of two residents and did not ensure the DPOA for another resident was properly invoked. Discrepancies were found between signed DNR sheets and physician's orders, and only one physician declared a resident incapacitated when two were required. Staff inconsistencies in recording and communicating code status were also noted.
The facility failed to maintain a safe, clean, and comfortable environment, with significant cleanliness issues, damaged furniture, and inadequate temperature control. Additionally, the facility did not provide a sufficient amount of bed linens, towels, and washcloths, causing discomfort and inconvenience to residents and staff. Interviews with staff and residents confirmed these deficiencies, and the facility's administration acknowledged the ongoing problems.
The facility failed to ensure residents knew how to file a grievance, as evidenced by interviews and observations. Thirteen residents stated they did not know how to file a grievance or who the grievance officer was. Staff members were also unaware of the grievance process, and the grievance forms were inaccessible to wheelchair-bound residents. The Administrator confirmed these issues and was unsure if residents were educated about the grievance process.
The facility failed to check the CNA Registry and complete necessary background checks for three staff members before hiring, as required by policy. Interviews with management confirmed that these checks should have been done prior to employment.
The facility failed to provide written notices of transfer or discharge to residents or their responsible parties, including necessary details and appeal rights, and did not notify the State LTC Ombudsman. This affected two residents with significant health issues. Staff were unaware of these requirements, and the facility lacked a policy for transfers and discharges.
The facility failed to inform two residents and their families of the bed hold policy during hospital transfers. One resident with cognitive impairments and multiple diagnoses was sent to the hospital after a fall, and another resident with severe medical conditions was hospitalized for sepsis and pneumonia. Both cases lacked documentation of bed hold notices, and staff were unaware of the policy.
The facility failed to complete the Minimum Data Set (MDS) assessments within the required time frames for three residents upon their admission. The delays were attributed to staffing changes and errors by the previous Regional MDS Coordinator, resulting in the facility receiving errors for these late submissions.
The facility failed to ensure complete, accurate, and individualized care plans for residents, leading to unaddressed needs such as assistance with ADLs, use of side rails, hospice services, and management of medical conditions like pressure ulcers and cellulitis. The lack of formal training and oversight in the care plan process contributed to these deficiencies.
The facility failed to ensure dependent residents received necessary services for personal hygiene and ADLs. Multiple residents missed scheduled showers, did not receive complete perineal care, and were not repositioned or toileted as needed. Staff cited insufficient staffing and lack of supplies as reasons for these deficiencies.
Facility staff failed to use proper techniques during transfers for three residents, leading to discomfort and potential harm. One resident experienced pain due to improper gait belt use, another was repositioned without a gait belt causing discomfort, and a third was transferred with a gait belt incorrectly placed, indicating a lack of understanding of proper techniques.
The facility failed to maintain the hydration status for three residents and all residents who attended a group meeting, as staff did not consistently pass fresh ice water. Interviews with residents and staff revealed that fresh ice water was not provided every shift due to insufficient staffing, contrary to the facility's policy for assisted nutrition and hydration.
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the management of oxygen concentrators and tubing. Observations revealed empty humidified water bottles, undated and improperly stored oxygen tubing, and uncleaned filters. Staff interviews indicated a lack of knowledge regarding proper respiratory care protocols.
The facility failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure the bed's dimensions were appropriate for the residents' size and weight. Additionally, the staff did not complete side rail assessments or obtain a physician's order prior to installation for five residents. The maintenance supervisor installed bed rails without conducting any assessments or measurements, and the administrator acknowledged that side rail assessments should be completed upon admission but were not being done properly.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights, lack of assistance with toileting, failure to reposition residents, inadequate feeding assistance, and missed showers. Residents reported long wait times and inconsistent care due to staff shortages, with observations confirming these issues. The facility's Director of Nursing and staff acknowledged the staffing problems, which compromised the quality of care provided to residents.
The facility failed to ensure staff administered medications with a medication error rate of less than 5%, resulting in a 24% error rate. Errors included improper administration of eye drops, nasal sprays, and insulin injections, as well as mishandling of oral medications. Staff were observed not following manufacturer guidelines and facility policies, leading to potential harm to residents.
The facility failed to ensure residents were free from significant medication errors when an LPN did not prime insulin pens before administering insulin to two residents, resulting in three significant medication errors. The facility's policy and manufacturer guidelines require priming, but this step was not followed.
The facility failed to ensure sufficient staffing to serve meals in a timely manner, affecting three residents. One resident with neurocognitive disorder was not assisted with meals, leading to cold, untouched food. Another resident with impaired cognition waited over 23 minutes for assistance and did not receive supper the previous night. A third resident also missed supper and had to be given a sandwich by the charge nurse. Staff and management acknowledged issues with staffing, training, and meal service.
The facility failed to have a comprehensive QAPI plan, affecting all 66 residents. The new Administrator could not locate any QAPI policies and procedures and reported that only one QAPI meeting had been held, attended by department heads, the staffing coordinator, and the dietary/housekeeping supervisor. Monthly discussions with the Medical Director were also mentioned.
The facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies as part of their QAA committee, affecting all 66 residents. The facility lacked a policy for their QAA process and was unable to provide records of the QAA and QAPI plan. The Administrator, who started recently, mentioned they had only conducted one QAPI meeting with department heads and other key staff.
The facility failed to have an Infection Prevention program and staff did not follow proper infection control practices. A CMT administered medications that had fallen on the floor to a resident, and CNAs did not wash hands between glove changes or clean up urine before placing a fall mat over it. Another CMT used bare hands to handle medication capsules.
The facility failed to establish an IPCP that included an antibiotic stewardship program to address antibiotic use protocols and monitor antibiotic use. A resident with multiple diagnoses, including a UTI, was prescribed antibiotics, but the facility lacked a system to map or track infections. The Administrator confirmed the absence of an active Antibiotic Stewardship Program.
The facility failed to maintain documentation showing that staff received training on abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention. Interviews with staff revealed inconsistencies in training, and the Administrator and Business Office Manager could not locate any inservice sheets.
The facility failed to ensure nurse aides received the required 12 hours of in-service education, including training on abuse, neglect, and dementia care. Interviews and record reviews revealed a lack of documentation and confirmed that the training had not been provided since the current administrator took over.
The facility staff failed to complete a comprehensive discharge summary for a resident with multiple diagnoses, including dementia and diabetes, who was discharged home with a Home Health agency. The Administrator admitted that no one was responsible for discharge summaries after the last MDS Coordinator left, and the facility lacked a discharge process policy.
The facility failed to ensure a resident with dementia had a personalized care plan, leading to inadequate management of the resident's aggressive behaviors. Staff lacked training in dementia care, and the facility did not complete a comprehensive MDS assessment or develop specific interventions for the resident's needs.
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 Ensure Dignified and Respectful Care
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect during care. Based on observation, interview, and record review, staff members were unnecessarily rough while providing care to these residents. This deficiency was identified among two of six sampled residents, with the facility census at 73 at the time of the survey. The report specifically notes that the actions of staff did not honor the residents' rights to a dignified existence, self-determination, and communication, as required by regulation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the Department of Health and Senior Services (DHSS) when a resident sustained an open fracture to the right femur. The Director of Nursing (DON) assessed the resident but did not report the injury to DHSS and did not immediately inform the Administrator. This deficiency was identified through interview and record review, and it affected one resident out of a facility census of 73. The report notes that this deficiency remains uncorrected and references previous similar findings.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to initiate an investigation into an injury of unknown origin when a resident sustained an open fracture to the right femur. The Director of Nursing assessed the resident but did not begin an investigation to determine the cause of the injury. This deficiency was identified through interview and record review and affected one resident out of a facility census of 73. The deficiency remains uncorrected, and previous similar examples are referenced in a prior Statement of Deficiencies.
Verbal and Physical Abuse of Resident by CMT
Penalty
Summary
Certified Medication Technician (CMT) A verbally and physically abused a resident with multiple medical conditions, including extreme binge eating disorder, obesity, anxiety, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and oxygen dependence. The resident required moderate assistance with activities of daily living and used a wheelchair for mobility. On the morning of the incident, CMT A yelled derogatory and disparaging terms at the resident, specifically referencing the resident's body type, and forcefully pushed the resident's wheelchair forward after the resident did not move as instructed. This behavior was witnessed by a housekeeping aide, who reported hearing CMT A repeatedly yell at the resident and then observed the aggressive physical action. The resident, when interviewed, denied being aware of any derogatory language or mistreatment and stated that staff were good to them. However, CMT A admitted to losing their temper, using inappropriate language, and pushing the resident's wheelchair with excessive force. Facility records confirmed that CMT A had received recent training on abuse and neglect. The facility's abuse prevention policy defines such actions as abuse, including both verbal and physical abuse, and requires the protection of residents from such treatment.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin after staff became aware that one resident had sustained a right leg femur fracture. Despite being informed of the injury on 2/27/25, the incident was not reported as required. This deficiency was identified during a revisit, where continued non-compliance was noted. The facility census at the time was 67 residents.
Failure to Investigate and Document Alleged Violation
Penalty
Summary
The facility failed to complete a thorough investigation after one resident sustained a femur fracture of unknown origin. There was no documentation maintained to show that the alleged violation was thoroughly investigated. This deficiency was identified through interview and record review, with a facility census of 67 residents. The lack of a comprehensive investigation and proper documentation regarding the incident involving the resident's femur fracture constituted a failure to respond appropriately to the alleged violation.
Failure to Provide Dignified and Respectful Care During Personal Care Activities
Penalty
Summary
Staff failed to treat two residents with dignity and respect during the provision of personal care. One resident, who was cognitively intact and dependent on staff for activities of daily living, reported that a CNA was unnecessarily rough while providing care, rolling the resident hard and fast, and using excessive force during perineal care. The resident also described discomfort due to staff yelling at each other over the resident during care. Multiple staff interviews confirmed that the CNA had a pattern of being rough with residents, and the incident was reported to nursing leadership. Another resident, who had moderate cognitive impairment, Parkinson's disease, and was dependent on staff for all activities of daily living, was observed receiving perineal care in a manner that was not gentle or respectful. The CNA providing care did not explain the procedure to the resident and scrubbed the resident's groin and perineal area vigorously, using an up and down motion, and did not communicate with the resident during the process. This was witnessed by another staff member, who described the care as rough and hurried. Facility policies required staff to provide care in a manner that upholds resident dignity and comfort, including gentle and person-centered perineal care. Interviews with staff and residents confirmed that the care provided did not meet these standards, as residents experienced rough handling, lack of communication, and discomfort during personal care tasks.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when one resident was observed with their hand down the front of another resident's pants. The incident occurred in a common area and was witnessed by another resident, who reported it to staff at the nurses' station. Two staff members, a Certified Medication Technician (CMT) and a Certified Nurses Assistant (CNA), both observed the inappropriate contact and intervened by redirecting the resident and assisting the affected resident to the dining room. The resident who initiated the contact had a history of dementia, anxiety, and physical aggression, with severely impaired cognitive skills as indicated by a low BIMS score. The resident who was touched also had severely impaired cognitive skills, spastic quadriplegic cerebral palsy, and other significant medical and communication challenges, but was able to answer yes/no questions. Both residents' care plans documented behavioral histories, including sexually inappropriate behaviors for the resident who was touched. Interviews conducted after the incident revealed that neither resident recalled or reported the inappropriate contact, and both stated they felt safe in the facility. The staff involved had not previously witnessed inappropriate behavior of this nature from the resident who initiated the contact. The facility's abuse prevention policy defines sexual abuse as non-consensual sexual contact of any type with a resident and emphasizes the commitment to protect residents from abuse by anyone.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner when staff became aware that a resident had sustained a right femur fracture. According to the facility's abuse, neglect, and exploitation policy, all alleged violations involving serious bodily injury must be reported to the administrator, state agency, and other required authorities immediately, but not later than two hours after the allegation is made. In this case, the resident, who had severe cognitive impairment, quadriplegia, and was dependent on staff for all activities of daily living, was found to have a right distal femur fracture with no known cause or mechanism of injury. The resident had a history of pain and required frequent pain management, but there were no documented falls or injuries in the six months prior to the incident. On the day the injury was discovered, the resident complained of new pain and swelling in the right knee after a shower, which led to a hospital evaluation and diagnosis of a displaced femur fracture. Staff interviews confirmed that no one knew how the injury occurred, and the resident had been fine prior to the shower. The Director of Nursing and Administrator both acknowledged that they were aware of the injury but did not report it as required, instead waiting for additional information from the hospital and corporate guidance. Despite the facility's policy and regulatory requirements, the injury of unknown origin was not reported to the appropriate authorities within the specified time frame. The Administrator and DON deferred reporting while awaiting further details, and the investigation did not reveal any specific event that could have caused the fracture. The failure to report the injury promptly constituted a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation and maintain adequate documentation following an incident in which a resident sustained a femur fracture of unknown origin. The resident, who had severe cognitive impairment, quadriplegia, aphasia, and was dependent on staff for all care and mobility, was found to have a right distal femur fracture after being sent to the emergency room for leg pain, swelling, and decreased oxygen saturation. Prior to the discovery of the fracture, the resident had been involved in a mechanical lift incident where the lift tipped and the resident was lowered to the floor, but no injuries were noted at that time and the event was only documented in the progress notes. The facility's policy required immediate and thorough investigation of possible abuse, neglect, or unexplained injuries, including identifying responsible staff, interviewing all involved parties, and providing complete documentation. However, the investigation into the resident's fracture consisted of a single-page document with brief staff interviews lacking dates, times, or written statements. The DON verbally interviewed staff but did not collect written statements or additional documentation, and was unable to identify which CNA was involved in the earlier mechanical lift incident. There was no evidence that all required investigative steps were followed or that the investigation was sufficiently documented. Interviews with staff and administration confirmed that no one knew how the fracture occurred, and that the investigation did not include written statements or comprehensive documentation. The administrator and DON both stated that they did not suspect abuse or neglect, but the lack of a thorough and well-documented investigation was contrary to facility policy and regulatory requirements for responding to injuries of unknown origin.
Failure to Update and Follow Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status of two residents was correctly documented and followed according to the guardians' directives. For one resident, the guardian had instructed the facility staff to change the resident's code status to Do Not Resuscitate (DNR) upon admission. However, the facility did not update the resident's records to reflect this change, and when the resident stopped breathing, cardiopulmonary resuscitation (CPR) was initiated against the guardian's wishes. Despite the guardian's repeated requests to stop CPR, the facility continued the resuscitation efforts until the resident was declared deceased. Another resident's guardian had also requested a change in the resident's code status from full code to DNR. The Social Services Designee (SSD) was informed of this request, but the facility failed to update the resident's code status. As a result, the resident remained listed as full code, and the necessary documentation to reflect the guardian's wishes was not completed. Interviews with facility staff revealed a lack of communication and responsibility in updating and confirming residents' code statuses. The Business Office Manager, Registered Nurses, and SSD all had differing accounts of their roles and responsibilities in obtaining and documenting code status changes. The physician was not informed of the desired changes, and the facility's policies and procedures for handling code status updates were not followed, leading to the deficiencies identified in the report.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported receiving food that was cold, unappetizing, and improperly handled. For instance, Resident #8 mentioned that their food was often sloshed together, breadsticks were soggy, and drinks were not covered, leading to spills. Similarly, Resident #2 and Resident #58 reported receiving cold food and uncovered drinks, with Resident #58 also noting that the food lacked taste and was not of the right consistency. Other residents, such as Resident #27 and Resident #56, complained about the food being tough, dry, and generally unappetizing. Resident #55 described the food as horrible and cold, while Resident #212 consistently received cold breakfasts. These observations were corroborated by staff interviews, where Certified Medication Technician B and Certified Nurse Aide A acknowledged that residents had complained about cold food and that there were struggles in serving food in a timely manner, especially during breakfast. Dietary staff also confirmed that room trays were often an issue, with food arriving cold due to delays in distribution. During a kitchen observation, it was noted that while food was initially cooked at appropriate temperatures, by the time it was served, it had significantly cooled down. For example, oatmeal that was initially 205.6 degrees was served at 104.5 degrees, and sausage patties that were 189.3 degrees were served at 119.5 degrees. A test tray at the end of meal service showed all food items were below the appropriate serving temperature of 135 degrees, with some items being as low as 87.4 degrees. Staff interviews revealed that there were ongoing issues with maintaining food temperatures, particularly for room trays, and that the facility was aware of these issues but had not yet fully addressed them. The Dietary Manager mentioned that they were aware of the complaints and had ordered insulated domes with metal heat plate inserts to help maintain acceptable serving temperatures for room trays.
Deficiencies in Food Service Safety and Hygiene Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards of food service safety. Staff with facial hair did not wear beard coverings, and there were multiple instances of staff failing to wash their hands at appropriate times. Specifically, dietary aides and the housekeeping supervisor were observed not wearing beard restraints, and dietary staff did not wash their hands between tasks, after touching potentially contaminated surfaces, or when entering and exiting the kitchen. This lack of adherence to hygiene protocols was confirmed through interviews with the staff and the administrator, who acknowledged the deficiencies in hand hygiene practices and the availability of beard coverings. The facility also failed to properly label and date food items, which is essential for maintaining food safety. Observations revealed undated and opened food items in the walk-in cooler and spice cabinet, including bags of cheese, containers of beef base, and various spices. Interviews with the dietary manager and aides confirmed that food items should be labeled and dated when opened, but this practice was not consistently followed. The dietary manager admitted to not knowing the specific guidelines for discarding spices in a long-term care setting. Additionally, the facility did not maintain a clean and sanitary kitchen environment. Observations showed caked-on dust on the coils of the fan in the cooler and behind the stove, as well as crumbs on the kitchen floor. The dietary manager admitted to not having a cleaning log for kitchen tasks, and the administrator acknowledged that the cleanliness of the facility was a work in progress. The lack of a systematic approach to kitchen cleanliness and sanitation was evident, contributing to the overall deficiency in food service safety standards.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to treat each resident with respect and dignity and provide care in a manner that promotes their quality of life. Staff did not knock on resident doors before entering and failed to announce themselves to two residents. Additionally, staff left the bedroom door to the hallway open while providing peri-care to one resident, exposing the resident's genital area to the hallway. Another resident's call light was not answered in a timely manner, resulting in the resident being incontinent of urine. These actions affected four residents out of the 17 sampled residents, with a facility census of 66. Resident #35, who has significant cognitive deficits and requires assistance for activities of daily living, was observed with their room door open and privacy curtain partially drawn while receiving peri-care. This exposed the resident's genital area to the hallway. The nurse aide acknowledged the mistake and stated that the door should have been closed. The Director of Nursing and the Administrator confirmed that room doors should be closed during such care. Resident #21, who has no cognitive deficits but requires partial assistance for activities of daily living, had their call light on for 45 minutes before a CNA responded. The resident was found to be incontinent of urine due to the delay. The CNA admitted to being busy with another resident and stated that there is not enough help to answer call lights immediately. The Administrator also acknowledged the staffing issue. Additionally, two other residents reported that staff frequently entered their rooms without knocking or announcing themselves, which made them feel disrespected and undignified.
Failure to Respect Resident Choice for Outdoor Access
Penalty
Summary
The facility failed to respect and facilitate the rights of two residents to make choices about significant aspects of their lives, specifically the ability to go outside unsupervised. Resident #45, who is cognitively intact and has a preference for going outside to get fresh air, reported that staff did not assist in facilitating this preference unless they were escorted. Similarly, Resident #212, who is also cognitively intact and has a history of waking up early to watch the sunrise, stated that they could not go outside alone and required supervision at all times. Both residents did not have care plans addressing their preferences for outdoor activities. During a group meeting, several residents expressed that they were not allowed to go outside unless accompanied by staff, and non-smokers had even fewer opportunities to go outside. Interviews with staff, including the Housekeeping Supervisor, Nurse Aide, Director of Nursing, and the Administrator, confirmed that residents were required to be supervised while outside due to safety concerns and staff availability. The facility did not have a courtyard available, and the landscape was described as sloping, which contributed to the decision to restrict unsupervised outdoor access.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The review of the facility's Resident Trust Bank Statements for the period from May 2023 through May 2024 showed an average monthly balance of $27,000.00. However, the Department of Health and Senior Services approved bond list revealed that the facility only had a $1,000.00 approved bond, making it insufficient by $22,000.00. During an interview, the Business Office Manager admitted that the facility had recently changed ownership and was unaware that the bond had not been reassessed since the new company took control. The Business Office Manager also acknowledged that the bond should be sufficient to cover the resident funds.
Failure to Provide Accessible Ombudsman Information
Penalty
Summary
The facility failed to protect resident rights by not providing accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency. The facility's policy mandates that residents receive a list of pertinent state regulatory and informational agencies, including the ombudsman program and the State Survey Agency. However, an observation on 5/7/24 revealed that the ombudsman poster was hung on a wall in the day room, but it was not visible to residents sitting in wheelchairs. Additionally, during a group interview, residents expressed that they did not know what an ombudsman was, where the information was posted, or how to reach the ombudsman. Twelve residents also did not know how to formally file a complaint with the state survey agency. During an interview on 5/9/24, the Administrator confirmed that the ombudsman contact information was posted in the day room but admitted to not knowing how residents had been educated on reaching the ombudsman representative or the state survey agency. The facility census at the time was 66, indicating a significant number of residents potentially affected by this deficiency.
Failure to Clarify Code Status and Invoke DPOA Properly
Penalty
Summary
The facility failed to clarify the code status of two residents and did not ensure the Durable Power of Attorney (DPOA) for Health Care Decisions for another resident was properly invoked. Resident #16's DPOA required activation by two physicians, but only one physician had declared the resident incapacitated. Despite this, the resident's DNR order was signed by the DPOA and a physician, and the resident's medical records indicated a DNR status. The Social Services Designee and the Administrator confirmed the requirement for two physicians to declare incapacity, which was not met in this case. For Resident #45, there was a discrepancy between the resident's signed DNR sheet and the physician's orders, which indicated a full code status. Similarly, Resident #214 had a signed DNR sheet, but the physician's orders showed a full code status. Interviews with staff revealed inconsistencies in how code status information was communicated and recorded, with some staff relying on stickers on room doors and others checking electronic medical records or care plans. The Director of Nursing and the Administrator both acknowledged that the code status in physician's orders should match the advance directives. The Social Services Designee was responsible for ensuring that advance directive paperwork was scanned and recorded accurately. However, the discrepancies in the code status documentation for Residents #45 and #214, as well as the improper activation of the DPOA for Resident #16, indicate a failure to adhere to the facility's policies and procedures regarding advance directives and code status documentation.
Facility Fails to Maintain Cleanliness, Temperature Control, and Adequate Linen Supply
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents. Observations revealed multiple areas with significant cleanliness issues, including cobwebs, dust, dirt, and debris on vents, handrails, and floors. Additionally, the facility had damaged and worn-out furniture, such as cracked dining room chairs and peeling love seats. The facility also did not maintain comfortable temperatures in common areas, with temperatures ranging from 65.8 to 84.7 degrees Fahrenheit, causing discomfort to residents who were observed covered in blankets and complaining about the cold or heat. Interviews with staff indicated that the air conditioning units were not functioning correctly, and there was a lack of clarity regarding cleaning responsibilities between housekeeping and maintenance staff. The facility also failed to provide a sufficient amount of bed linens, towels, and washcloths. Observations and interviews with residents and staff revealed that the facility often ran out of necessary linens, forcing staff to use fitted sheets instead of top sheets and causing delays in providing clean towels for resident showers. The Dietary and Laundry Manager confirmed the shortage of linens and the challenges in maintaining an adequate supply due to missing items and limited laundry staff availability. Staff expressed frustration with the lack of access to linen supplies, which hindered their ability to provide proper care to residents. Resident #8, who had cognitive skills intact and required assistance with daily activities, reported not receiving a clean top sheet despite requesting one. The resident was covered with a fitted sheet instead, highlighting the facility's failure to meet basic hygiene and comfort needs. Interviews with various staff members, including the Maintenance Supervisor, Housekeeping Aide, and Certified Medication Technicians, further corroborated the issues with cleanliness, temperature control, and linen shortages. The Administrator and Director of Nursing acknowledged the deficiencies and the ongoing problems with maintaining a sufficient supply of linens.
Failure to Ensure Residents Knew How to File a Grievance
Penalty
Summary
The facility failed to ensure residents knew how to file a grievance, as evidenced by interviews and observations. During a group meeting, all thirteen residents present stated they did not know how to file a formal grievance or who the grievance officer was. Observations showed that the grievance forms were placed in a red folder on the wall, which was inaccessible to residents in wheelchairs. Additionally, staff members, including the housekeeping supervisor, Dietary Manager, Nurse Aide, and Licensed Practical Nurse, were unaware of the facility's grievance process or the location of the grievance forms. The Administrator confirmed that the grievance folder was not accessible to wheelchair-bound residents and was unsure if residents were educated about the grievance process. The facility's policy on resident rights indicated that residents have the right to voice grievances without discrimination or reprisal and should be informed on how to file a grievance. However, the lack of knowledge among residents and staff about the grievance process and the inaccessibility of grievance forms for wheelchair-bound residents indicate a failure to adhere to this policy. The Administrator also mentioned that the facility had a corporate compliance line but was unsure if this information was provided to residents. The Social Service Designee was expected to educate residents about the grievance process during the 48-hour care plan meeting, but it was unclear if this was effectively communicated to all residents.
Failure to Conduct Required Background Checks and Registry Verifications
Penalty
Summary
The facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator, which is a marker given by the federal government to individuals who have committed abuse or neglect. This deficiency affected three of ten sampled staff members: a Certified Medication Technician (CMT), a Dietary Aide, and a Licensed Practical Nurse (LPN). Specifically, the employee files for these staff members showed that necessary background checks, including the Family Care Registry and Employee Disqualification List (EDL) checks, were either not completed or were completed significantly after the date of hire. Interviews with the Business Office Manager, Director of Nursing, and the Administrator revealed that background checks and registry checks should be completed before hiring employees. However, the facility did not follow these procedures consistently. The Business Office Manager, who started in the position recently, confirmed that Family Care Registry checks should be done before hiring, but acknowledged that the facility did not perform periodic background checks on employees. The Director of Nursing and the Administrator both stated that background checks and Nurse Aide Registry checks should be completed prior to employment, but this was not done for the affected staff members.
Failure to Provide Proper Transfer/Discharge Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to residents or their responsible parties, which included the reason for the transfer, the effective date, the location, and information regarding appeal rights. Additionally, the facility did not notify the State Long-Term Care Ombudsman of the transfers and discharges. This deficiency affected two residents, one of whom had a stroke, Alzheimer's disease, and other significant health issues, and another who was hospitalized for sepsis and pneumonia. The facility did not have a policy for the transfer or discharge of residents, and staff were unaware of the requirements for notifying the Ombudsman and providing appeal rights information. Resident #27, who had cognitive impairments and multiple health conditions, was found on the floor with a large hematoma and was transferred to the hospital. The medical record did not contain a transfer or discharge letter for the resident or their responsible party. Interviews with staff revealed that they were unaware of the need to include appeal rights and notify the Ombudsman. Resident #14, who was cognitively intact but dependent on staff for most activities, was hospitalized for sepsis and pneumonia. The medical record also lacked a transfer or discharge letter. Interviews with the new Administrator and Director of Nursing indicated that they were not aware of the requirement to notify the Ombudsman or provide a notice of transfer and discharge. The facility did not have a transfer packet or policy in place to ensure compliance with these requirements.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that staff informed residents and their family/legal representatives of the bed hold policy at the time of transfer or discharge to the hospital for two of the 17 sampled residents. Resident #27, who had cognitive impairments and multiple diagnoses including stroke and Alzheimer's disease, was sent to the hospital after a fall. There was no documentation in the medical record that the resident or the responsible party was provided with written information explaining the facility's bed-hold policy. During an interview, an LPN stated that they were not aware of any bed hold letter/notice that needed to be sent with the resident. Similarly, Resident #14, who was cognitively intact but had multiple severe medical conditions including quadriplegia and chronic pain, was hospitalized for over a week due to sepsis and pneumonia. The resident did not recall receiving a bed hold notice at the time of hospitalization. The medical record also lacked documentation of a bed hold notice. Interviews with the Director of Nursing and the Administrator revealed that they were unaware of the bed-hold policy and could not find any discharge packet that included a bed-hold notice.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments within the required time frames for three residents (Resident #214, #216, and #212) upon their admission. Resident #214 was admitted with diagnoses including rheumatoid arthritis and generalized muscle weakness, but the MDS was not completed until after the required deadline. Similarly, Resident #216, who had diagnoses including neurocognitive disorder with Lewy bodies and chronic pain syndrome, also had a delayed MDS submission. Resident #212, with conditions such as dependence on renal dialysis and diabetes, did not have an MDS completed within the required timeframe either. The State RAI Coordinator confirmed that the MDS assessments for these residents were submitted late and the facility received errors for these delays. Additionally, the facility did not provide a policy regarding comprehensive assessments, which is a requirement for ensuring timely and accurate resident evaluations. The Social Service Designee and the Administrator acknowledged the delays and attributed them to staffing changes and errors made by the previous Regional MDS Coordinator. The facility's failure to complete these assessments on time indicates a lapse in adhering to federally mandated assessment protocols, which are crucial for developing appropriate care plans for residents.
Incomplete and Inaccurate Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #162, the care plan did not include necessary details such as assistance with ADLs, use of side rails, hospice services, use of a catheter, or use of oxygen. Despite the resident having an unwitnessed fall and the presence of side rails on the bed, these were not documented in the care plan. Additionally, there was no progress note about the fall, and the use of side rails was not ordered by the physician or included in the care plan. Resident #45's care plan was also incomplete, missing details about side rails, shower preferences, activity preferences, and pressure ulcers. The resident had a side rail installed to assist with bed mobility but had not used it since moving to a recliner due to leg swelling. The resident expressed a preference for showers twice a week, but the shower logs showed that only 2 out of 9 scheduled showers were provided. The resident also had a pressure ulcer and cellulitis, which were not adequately addressed in the care plan. For Resident #216, the care plan was not completed despite the resident being admitted to the facility and having significant medical needs, including impaired cognition, chronic pain, and the use of antipsychotic medications. The resident's representative reported not participating in any care plan meetings, and the facility had not provided team collaboration or communication regarding the resident's care. Similarly, Resident #214's care plan was incomplete, only addressing do-not-resuscitate orders despite the resident having multiple medical conditions and requiring assistance with various ADLs. The facility's Social Service Designee and Administrator acknowledged the deficiencies, noting a lack of formal training and oversight in the care plan process.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. This deficiency affected multiple residents, including those who did not receive complete perineal care and those who missed scheduled showers. For instance, one resident reported going two weeks without a shower, feeling filthy and neglected, while another resident's hair appeared dull and greasy, indicating a lack of proper hygiene care. Staff interviews revealed that showers were often missed due to insufficient staffing and a lack of necessary supplies like towels and washcloths. Additionally, the designated shower aide was frequently reassigned to other duties, further exacerbating the issue. In another instance, a resident with severe cognitive impairment and incontinence was observed sitting in a Broda chair with a puddle of urine underneath. The staff failed to provide thorough perineal care, did not clean the resident's chair, and used a clean incontinent brief that had fallen on the floor. The staff also did not wash their hands before and after providing care, and the resident's room was left with urine on the floor, covered by a fall mat. Interviews with the staff confirmed that they were aware of the proper procedures but failed to follow them due to time constraints and staffing issues. Another resident, who was dependent on staff for repositioning and toileting, was observed being left in a Broda chair for extended periods without being repositioned, offered food or drinks, or taken to the restroom. The resident was visibly distressed, crying, and expressing discomfort, but staff did not promptly address these needs. The facility's failure to provide adequate care and assistance with ADLs, including repositioning, toileting, and maintaining personal hygiene, was evident across multiple cases, highlighting significant deficiencies in the care provided to residents.
Improper Transfer Techniques and Gait Belt Use
Penalty
Summary
The facility staff failed to use proper techniques to reduce the possibility of accidents and injuries during the use of a gait belt transfer for Resident #9 and properly transfer two residents, Resident #21 and Resident #4, in a manner to prevent accidents. Resident #21, who had no cognitive deficits and required partial to moderate assistance for standing and transfers, was observed being transferred by a CNA without the use of a gait belt, causing discomfort and potential harm. The resident reported that the improper technique sometimes caused pain, especially when staff did not use a gait belt, pulling on the resident's pacemaker and twisting the skin. Resident #4, who had significant cognitive deficits and required substantial to maximum assistance with ADLs, was observed being repositioned in a dining room chair by a CNA without the use of a gait belt. The CNA used their forearm under the resident's armpit to pull and drag the resident, causing the resident to grunt loudly in discomfort. The resident's care plan indicated the need for a gait belt to assist with transfers and ambulation due to the resident's tendency to lean to one side. Resident #9, who had severe cognitive impairment and required substantial to maximal assistance with transfers, was observed being transferred by two CNAs using a gait belt incorrectly placed under the resident's breasts. The gait belt slid up between the resident's shoulder blades during the transfer, indicating improper technique. Interviews with the CNAs revealed a lack of understanding of the correct placement and use of the gait belt, contributing to the unsafe transfer practices observed.
Failure to Maintain Resident Hydration Status
Penalty
Summary
The facility failed to ensure staff maintained the hydration status for three of the 17 sampled residents and all residents who attended the group meeting. Specifically, staff did not pass fresh ice water to the residents as required. Resident #2, who had diagnoses including seizure disorder, depression, and coronary artery disease, reported that staff rarely passed fresh ice water each shift, and their water pitcher was less than half full without any ice. Resident #8, who had diagnoses including anxiety, depression, and anemia, also reported that staff did not pass fresh ice water every shift, and their water pitcher lacked ice. Resident #56, with diagnoses including cancer, anxiety, depression, pneumonia, respiratory failure, and COPD, similarly reported that staff did not pass fresh ice water every shift, and their water pitcher was less than half full without a lid or ice. During a group interview, residents confirmed that they often had to ask for fresh ice water, and some reported that staff did not pass water at all. Interviews with facility staff, including a Certified Medication Technician (CMT) and a Certified Nurse Aide (CNA), revealed that fresh ice water was not passed every day due to insufficient staffing. The CMT stated that fresh ice water was usually only provided if a resident specifically requested it. The CNA confirmed that fresh ice water was not passed every shift. The Administrator and the Director of Nursing (DON) acknowledged that staff should be passing fresh ice water every shift and sometimes twice a shift, but this was not consistently happening. The facility's policy for assisted nutrition and hydration emphasized the importance of providing sufficient fluid intake to maintain proper hydration and health, but this policy was not being followed in practice.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the management of oxygen concentrators and tubing. For Resident #7, who has a history of traumatic brain injury and chronic obstructive pulmonary disease (COPD), the oxygen concentrator was observed to be set at 2 liters per nasal cannula (2L/NC) instead of the ordered 3L/NC, and the humidified water bottle was empty. Additionally, the oxygen tubing was not dated, which is a critical step in ensuring timely replacement and hygiene. The resident's care plan and physician's orders were not followed accurately, contributing to the deficiency observed during the surveyor's visit on 5/6/24. For Resident #56, who has diagnoses including cancer, pneumonia, anxiety, depression, respiratory failure, and COPD, similar issues were noted. The resident's oxygen concentrator had an empty humidified water bottle, and the oxygen tubing was not dated and was found lying on the floor. The filter on the oxygen concentrator was covered in gray lint, indicating it had not been cleaned properly. The nebulizer tubing and mask were also not replaced as per the monthly schedule. Interviews with staff revealed a lack of knowledge regarding the frequency of changing and dating the tubing, as well as cleaning the filters, further highlighting the facility's failure to adhere to proper respiratory care protocols.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure the bed's dimensions were appropriate for the residents' size and weight. Additionally, the staff did not complete side rail assessments or obtain a physician's order prior to installation for five of the seventeen sampled residents. This deficiency was observed in residents who had varying degrees of cognitive and physical impairments, including those with neurocognitive disorders, quadriplegia, and chronic pain syndromes. The facility census was 66, and no policy on side rails was provided by the facility. Resident #45, who was cognitively intact and had impairments on one side, had a bed rail installed without a proper assessment or physician's order. The resident requested the side rail to assist with turning in bed, but the care plan did not include the use of bed rails. Similarly, Resident #216, who had a neurocognitive disorder and was dependent on staff for mobility, had side rails installed without any documented assessment or physician's order. The resident's bed was not lowered to the ground, increasing the risk of injury. Other residents, such as Resident #14 and Resident #1, also had side rails installed without proper assessments or physician's orders. Resident #14, who was cognitively intact but dependent on staff for most activities of daily living, requested side rails to help with turning in bed. Resident #1, who had severe cognitive loss and was dependent on staff for mobility, had a full side rail installed without padding, posing a risk of injury. The facility's maintenance supervisor admitted to installing bed rails without conducting any assessments or measurements, and the administrator acknowledged that side rail assessments should be completed upon admission but were not being done properly.
Staffing Shortages Lead to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of six out of 17 residents. This deficiency was evidenced by delayed responses to call lights, lack of assistance with toileting, failure to reposition residents, inadequate feeding assistance, and failure to provide showers twice a week. Residents reported long wait times for call lights, especially on weekends, and inconsistent shower schedules due to staff shortages. Observations confirmed these issues, with one resident waiting over an hour for assistance to use the bathroom, resulting in incontinence and embarrassment. Resident #21, who was cognitively intact and required partial assistance for activities of daily living (ADLs), reported waiting over an hour for call light responses, particularly on weekends. Observations showed an 18-minute delay in answering the resident's call light, leading to an incident of incontinence. Similarly, Resident #57, who had significant cognitive deficits and was dependent on staff for ADLs, was observed not being repositioned or offered food and drinks for extended periods, despite being in a Broda chair for several hours. Other residents, such as Resident #45, #50, and #39, also experienced issues with shower schedules and personal hygiene due to staff shortages. The facility's Director of Nursing and other staff members acknowledged the staffing issues, noting that shower aides were often pulled to cover other shifts, leading to missed showers and delayed care. Additionally, Resident #216, who required assistance with eating, was not fed in a timely manner, with family members having to step in to ensure the resident received meals. The facility's failure to provide adequate staffing resulted in unmet resident needs and compromised care quality.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure staff administered medications with a medication error rate of less than 5%, resulting in a medication error rate of 24%. This affected six of the 17 sampled residents. The errors included improper administration of eye drops, nasal sprays, and insulin injections, as well as mishandling of oral medications. Certified Medication Technician (CMT) A and Licensed Practical Nurse (LPN) A were observed making multiple errors during medication administration, including not applying lacrimal pressure for eye drops, touching the tip of the eye dropper to residents' eyelashes, not following manufacturer guidelines for nasal sprays, and not priming insulin pens before administration. Additionally, CMT A was observed picking up dropped medications from the floor and cart with bare hands and administering them to a resident, which is against facility policy and professional standards of practice. Resident #39 was prescribed Dorzolamide-timolol ophthalmic drops for cataracts, but CMT A did not apply lacrimal pressure after administration. Resident #51, who was prescribed Polymyxin b sulf-trimethoprim ophthalmic drops for an eye infection, experienced multiple errors during administration, including the tip of the eye dropper touching the resident's eyelashes and the failure to apply lacrimal pressure. Resident #6, who was prescribed Fluticasone nasal spray for allergy symptoms, did not receive the medication according to manufacturer guidelines, as CMT A did not shake the bottle, have the resident blow their nose, or close one side of the nostril before administration. Resident #34, who had multiple prescriptions for various conditions, experienced a medication error when CMT A dropped medications on the floor and cart, picked them up with bare hands, and administered them to the resident. Resident #56 and Resident #47, both diagnosed with diabetes, did not receive their insulin injections according to manufacturer guidelines, as LPN A did not prime the insulin pens before administration. These deficiencies indicate a lack of adherence to medication administration policies and professional standards of practice, resulting in a high medication error rate and potential harm to residents.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when staff did not prime insulin pens for two residents, resulting in three significant medication errors out of the 25 sampled medications. The facility's policy for medication administration requires medications to be administered as ordered and in accordance with manufacturer specifications. However, during observations, an LPN did not prime the insulin pens before administering insulin to two residents, despite the manufacturer's guidelines stating that the pen should be primed with 2 units before each injection. This failure was observed during the administration of Novolog, Lantus, and Victoza insulin pens. Resident #56, who has a diagnosis of diabetes and requires set-up assistance with ADLs, received an insulin injection without the pen being primed. Similarly, Resident #47, who has diagnoses of diabetes, congestive heart failure, and a cardiac pacemaker, also received insulin injections from unprimed pens. The LPN involved stated that they did not believe priming was necessary. The Director of Nursing and the Administrator confirmed that staff are expected to follow manufacturer guidelines, which include priming the insulin pens before each use.
Insufficient Staffing for Meal Service
Penalty
Summary
The facility failed to ensure sufficient staffing to serve meals to residents in a timely manner, affecting three residents. Resident #216, diagnosed with neurocognitive disorder with Lewy bodies, generalized osteoarthritis, and chronic pain syndrome, was observed multiple times with untouched, cold meals. Interviews with the resident's family and staff confirmed that the resident was not being assisted with meals, and family members had to step in to ensure the resident was fed. There was no documentation of the resident's meal intakes in the electronic medical record, and staff admitted to not having enough time to assist or document due to staffing shortages. Resident #16, who had moderately impaired cognition and required substantial assistance with eating, received a lunch tray that sat untouched for over 23 minutes before staff assisted. The resident did not receive supper the previous night, and staff had to prepare a peanut butter and jelly sandwich as an alternative. Staff interviews revealed that the delay in assistance and missed meals were due to insufficient staffing and new staff being unfamiliar with residents. Resident #8, who had intact cognition and required setup assistance with eating, also reported not receiving supper the previous night. The charge nurse had to prepare a peanut butter and jelly sandwich for the resident. The Dietary Manager and Administrator acknowledged issues with meal service, citing staff turnover, lack of training, and insufficient staffing as contributing factors. The Administrator confirmed that five residents did not receive their dinner trays on the specified night and that insufficient staffing had caused issues with meal service and resident assistance.
Lack of Comprehensive QAPI Plan
Penalty
Summary
The facility failed to have a Quality Assurance and Performance Improvement (QAPI) plan and did not have a plan that contained all required elements, affecting all 66 residents. The Administrator, who started on 3/14/24, was unable to locate any policies and procedures for QAPI. The facility had only conducted one QAPI meeting, attended by all department heads, the staffing coordinator, and the dietary/housekeeping supervisor. The Administrator also mentioned having monthly discussions with the Medical Director.
Failure to Implement QAA Plans of Action
Penalty
Summary
The facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. This affected all the residents in the facility, which had a census of 66. The facility did not provide a policy regarding their QAA process or committee and was unable to provide records of the QAA and Quality Assurance/Performance Improvement (QAPI) plan. During an interview, the Administrator, who started on 3/14/24, stated she was unable to locate the policy and procedures for QAPI and mentioned that they had only conducted one QAPI meeting. The meeting included all department heads, the staffing coordinator, and the dietary/housekeeping supervisor. The Administrator also mentioned that she talks to the Medical Director monthly.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to have an Infection Prevention program, including policies and procedures for infection control. During an interview, the Administrator admitted that there was no one currently responsible for the infection prevention program, and many policies were missing. The Assistant Director of Nursing was designated to handle the infection prevention program, but the facility was still working on updating and implementing necessary policies and procedures. For Resident #34, the Certified Medication Technician (CMT) failed to follow proper medication administration protocols. The CMT knocked over a medication cup, causing medications to fall on the floor and the top of the medication cart. The CMT then picked up the medications with bare hands and placed them back into the medication cup, which was then given to the resident. This action violated the facility's policy, which states that medications should not be touched with bare hands and that any medication that falls on the floor should be destroyed. For Resident #9, the facility staff failed to follow acceptable infection control practices during personal care. The Certified Nurses Aides (CNAs) did not wash their hands between glove changes and used a clean incontinent brief that had fallen on the floor. Additionally, they did not clean up a puddle of urine from the floor before placing a fall mat over it and did not clean the resident's Broda chair. These actions were against the facility's expectations and infection control standards. Similarly, for Resident #35, the CMT used bare hands to pull apart medication capsules and place them in pudding, which was then administered to the resident, violating the facility's medication administration policy.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program to address antibiotic use protocols and a system to monitor antibiotic use. The facility, with a census of 66, did not provide a policy regarding infection control and prevention. A resident with no cognitive deficit, dependent for activities of daily living, and diagnosed with cerebral infarction, cardiovascular disease, muscle spasms, and cystitis, was prescribed antibiotics for a urinary tract infection. However, the facility did not have a system in place to map or track infections, and no one was responsible for completing these tasks. The Administrator confirmed that the Director of Operations was running reports off-site, but there was no active Antibiotic Stewardship Program at the time of the survey. An Assistant Director of Nursing had been hired but had not yet started and would be responsible for the IPCP and Antibiotic Stewardship.
Lack of Staff Training Documentation on Abuse and Neglect
Penalty
Summary
The facility failed to maintain documentation showing that staff received training on abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention. The facility census was 66. During interviews, a Nurse Aide (NA) and a Certified Medication Technician (CMT) both reported not receiving any abuse and neglect training at the facility. Another Certified Nurse Aide (CNA) mentioned having received such training. The Administrator, who had been in the role since March, acknowledged that no abuse and neglect training had been conducted during their tenure and could not locate any inservice sheets from previous training sessions. The Business Office Manager also could not find any documentation of the required training.
Failure to Provide Required In-Service Education
Penalty
Summary
The facility failed to ensure that nurse aides received a minimum of 12 hours of in-service education per year, including training on abuse, neglect, and dementia care. This deficiency was identified through interviews and record reviews, which revealed that three randomly selected nurse aides did not have documentation of the required training. The facility's policy mandated staff training on these topics, but the administrator and business office manager could not locate any records of such training. Interviews with the nurse aides confirmed that they had not received the necessary training on abuse, neglect, or dementia care since the current administrator took over in March.
Failure to Complete Comprehensive Discharge Summary
Penalty
Summary
The facility staff failed to complete a comprehensive discharge summary for a resident who was discharged home with a Home Health agency for nursing, Physical Therapy, and Occupational Therapy. The resident had multiple diagnoses, including diverticulosis of the intestine, Type 2 diabetes mellitus, mild neurocognitive disorder with behavioral disturbance, dementia with psychotic disturbance, alcohol dependence, acute metabolic acidosis, and hallucinations. Despite the detailed care plan and progress notes indicating the discharge process, there was no discharge summary completed for the resident. During an interview, the Administrator admitted that no one was currently responsible for completing discharge summaries and was unsure who took over the responsibility after the last Minimum Data Set (MDS) Coordinator left. The facility also did not provide a policy regarding the discharge process, indicating a lack of clear procedures and accountability in ensuring comprehensive discharge documentation.
Failure to Provide Personalized Dementia Care Plan
Penalty
Summary
The facility failed to ensure a resident diagnosed with dementia had a personalized plan of care to address their specific needs. The resident, admitted on 4/22/24, had a primary diagnosis of neurocognitive disorder with Lewy bodies and exhibited severely impaired cognition. Despite this, the facility did not complete a comprehensive Minimum Data Set (MDS) assessment or develop a care plan that included specific nursing interventions, activities, or behavioral strategies for dementia care. The baseline care plan only addressed general care needs and did not provide detailed interventions for managing the resident's dementia-related behaviors, such as agitation, aggression, and hallucinations. The resident's medical records and staff interviews revealed multiple instances of combative and aggressive behavior, including hitting, biting, and yelling at staff during care. Staff attempted to manage these behaviors with as-needed medications like Haldol and Zyprexa, but there was no evidence of a structured approach to dementia care. Interviews with staff members, including CNAs and LPNs, indicated a lack of training on dementia care and specific strategies for interacting with this resident. Staff reported that they had not received any guidance or training from the facility on how to manage the resident's behaviors effectively. The facility's administration acknowledged the deficiencies in dementia care training and care plan development. The Social Service Designee and Administrator confirmed that the facility did not have a dedicated MDS coordinator to oversee care plans and that staff were not adequately trained in dementia care. The facility also lacked documentation of any dementia care training provided to staff. This lack of a structured care plan and appropriate training led to inadequate management of the resident's dementia-related behaviors, resulting in distress for the resident and challenges for the caregiving staff.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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