Bethesda Dilworth
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 9645 Big Bend Blvd, Saint Louis, Missouri 63122
- CMS Provider Number
- 265764
- Inspections on file
- 31
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Bethesda Dilworth during CMS and state inspections, most recent first.
The facility failed to maintain accurate controlled substance records when required shift-change narcotic counts were not completed and documentation for a resident’s oxycodone-acetaminophen was inaccurate. A resident with multiple chronic conditions had an order for scheduled oxycodone-acetaminophen, and a CMT removed and administered a dose without signing it out before administration. Later, the CMT documented the dose based on a prior quantity of six pills, resulting in a recorded balance of five, while only four pills were actually present in the card. The CMT reported arriving late and not completing the narcotic count, and an LPN acknowledged assuming, but not verifying, that counts had been done, contrary to facility policy requiring beginning- and end-of-shift counts and immediate documentation of narcotic removal.
The facility did not complete required wound assessments, failed to document wound characteristics, and did not follow its own policies for wound photography and physician notification for multiple residents. One resident's pressure ulcer worsened, leading to sepsis and emergency surgery, and treatment orders were not followed for two residents.
The facility did not notify physicians or resident representatives when three residents developed new or worsening pressure ulcers. Despite facility policy requiring notification and documentation, staff failed to inform the appropriate parties or record these notifications in the medical record. Interviews confirmed inconsistent notification practices, and wound care orders were sometimes entered without prior physician contact.
A resident with multiple complex medical conditions and a history of falls was discharged home alone without necessary home health care services or wound care education. The facility did not involve the resident, family, or IDT in discharge planning, failed to document evaluation of discharge needs, and did not discuss or document safer discharge options, resulting in a lack of a comprehensive, person-centered discharge plan.
A resident with multiple comorbidities and a chronic coccygeal wound did not receive pressure ulcer treatments as ordered, and the physician was not notified when the wound developed drainage and a foul odor. The resident was discharged home alone without home health RN services or wound care instructions, and there was no documentation of appropriate wound care or education prior to discharge.
The facility failed to provide care consistent with professional standards for residents with PICC lines. A resident did not receive antibiotics for two days due to a lack of orders, and another resident's PICC line was not properly maintained. The admitting nurse did not verify the purpose of the PICC lines or obtain necessary orders, leading to deficiencies in care.
A resident with moderate cognitive impairment and mobility assistance needs was injured during a transfer when staff deviated from the care plan due to a dead battery in the sit-to-stand lift. The staff performed a two-person assist transfer, resulting in the resident's foot being caught under the bed and causing a tibial plateau fracture. The incident was not immediately reported, and the injury was discovered after the resident complained of pain.
A resident with moderate cognitive impairment and requiring substantial assistance was improperly transferred by two CNAs when a sit-to-stand lift's battery failed. This resulted in a tibial plateau fracture. The incident was not reported to DHSS as required by the facility's policy, as the Administrator believed it was a witnessed event.
A resident was discharged without an appropriate immediate discharge letter, which lacked essential information such as the effective date of discharge, the specific location of transfer, and details on how to appeal. The resident exhibited aggressive behavior after a medication change, leading to a psychiatric evaluation and transport to a hospital. The facility's discharge form was incomplete, and the Administrator was unaware of the correct Ombudsman's office address.
Failure to Maintain Accurate Controlled Substance Counts and Documentation
Penalty
Summary
The facility failed to maintain accurate records for controlled substances when shift-change narcotic counts were not completed and a narcotic count sheet for one resident was inaccurate. The facility’s policy required all controlled substances to be immediately added to the controlled substance log upon delivery, and required incoming and outgoing nurses or CMTs to count all Schedule II–V controlled substances at the beginning and end of each shift, documenting verification on the controlled substance log. The policy also required immediate reporting and investigation of any missing medications or discrepancies. For Resident #7, who had diagnoses including rheumatoid arthritis, chronic kidney disease, heart failure, low back pain, and diabetes, there was an active order for oxycodone-acetaminophen 10-325 mg to be given four times daily. During observation, a CMT opened the narcotic box, removed one oxycodone-acetaminophen tablet for the resident, and verified that four pills remained in the card. The CMT administered the medication but did not sign it out of the controlled substance book prior to administration, contrary to the facility’s expectations that narcotics be signed out immediately upon removal. When the CMT later went to sign out the dose, the controlled substance sheet showed a previous quantity of six pills, with one signed out for a total of five, while the actual card contained only four pills. The CMT reported that he/she had arrived late and the narcotic counts were not done at the start of the shift. The LPN on duty stated that counts should be done at the beginning and end of each shift but had assumed, without verifying, that the counts were completed. The DON and Administrator both stated they expected staff to complete shift-change counts and to sign out narcotics immediately upon removal, but these processes were not followed in this instance, resulting in an inaccurate narcotic record and inability to reconcile the controlled substance count.
Failure to Prevent and Manage Pressure Ulcers and Notify Physician
Penalty
Summary
The facility failed to maintain an effective skin management program to prevent the development and worsening of pressure injuries. Specifically, wound assessments were not completed as required for two residents, with missing documentation on wound location, stage, size, characteristics, periwound, and wound edge descriptions. Additionally, the facility did not follow its own policy regarding wound photographs and measurements for three residents. There was also a failure to contact the physician prior to initiating a wound treatment order for one resident, and the required SBAR communication tool was not completed when new or worsening wounds were observed. Notification of the physician and family was not performed for three residents experiencing changes in wound status. One resident's pressure ulcer deteriorated, developing drainage and a foul odor, which ultimately required emergency surgery and resulted in a diagnosis of sepsis. Treatment orders were not followed for two residents, further contributing to the deficiencies. The sample size for the review was four residents, with a facility census of 151 at the time of the survey. The facility's policies outlined clear procedures for wound assessment, documentation, and communication, including weekly wound rounds, use of the Braden Scale for risk assessment, and specific documentation requirements for wound characteristics and interventions. Despite these policies, the facility did not adhere to the established protocols, resulting in delayed or incomplete assessments, lack of timely physician notification, and failure to implement or document appropriate interventions for residents with pressure injuries.
Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician and the resident's representative or family member after residents experienced a change in condition, specifically the development or worsening of pressure ulcers. This deficiency was identified through interviews and record reviews for three out of four sampled residents. The facility's policy requires licensed nurses to report changes in condition, incidents, or injuries to both the physician and the resident's representative or family member, and to document these notifications in the medical record. For one resident with severe cognitive impairment and multiple diagnoses, including acute kidney injury and altered mental status, skin assessments revealed the development of a coccyx pressure ulcer and a blister on the right heel. Despite these findings, there was no documentation of notification to the physician or family regarding these changes. Orders for wound care were entered without prior physician notification, and subsequent wound assessments continued to show no evidence of required notifications, even as the wounds progressed and developed drainage and odor. Another resident with moderate cognitive impairment and diagnoses such as hemiplegia, peripheral vascular disease, and diabetes developed multiple pressure injuries on the buttocks and heels. The medical record showed no documentation of physician or family notification for these wounds. A third resident, who was cognitively intact, also developed a coccyx pressure injury, with no evidence of notification to the physician or family. Staff interviews confirmed inconsistent practices regarding notification responsibilities, with some staff indicating that notifications were not routinely made for new or worsening wounds or changes in treatment orders.
Failure to Develop and Implement Effective Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that addressed the resident's discharge goals, needs, and capacity for discharge. The discharge plan did not involve the resident, family, or the interdisciplinary team (IDT) in a meaningful way, nor did it include interventions to ensure a smooth and safe transition to the post-discharge setting. There was no documentation of an evaluation of the resident's discharge needs, nor evidence that the results of any such evaluation were discussed with the resident or family and incorporated into the discharge plan, which is required as part of the comprehensive care plan. The facility did not document discussions with the resident or family about the implications or risks of being discharged to a location that was not equipped to meet the resident's needs. There was no record of presenting or discussing other, more suitable discharge options, nor documentation that the resident refused those options. Additionally, the facility did not determine if a referral to Adult Protective Services or another state entity was necessary, despite the resident being discharged to a potentially unsafe environment. Changes in the resident's condition that impacted the discharge plan were not identified, and necessary revisions to interventions were not made. A resident with multiple complex medical conditions, including diabetes, chronic heart failure, atrial fibrillation, chronic kidney disease, and a chronic coccygeal wound, was discharged home alone without required home health care services or education on wound care. The resident required assistance with transfers, ambulation, and activities of daily living, and had a history of falls, including a recent fall at home after a previous discharge. The facility's own policies required comprehensive discharge planning, interdisciplinary involvement, and documentation, none of which were adequately followed in this case.
Failure to Provide Ordered Pressure Ulcer Care and Discharge Planning
Penalty
Summary
The facility failed to provide pressure ulcer care and prevention in accordance with its own policies and physician orders for one resident. Specifically, the facility did not administer pressure ulcer treatments as ordered and did not notify the physician when the resident's coccyx/sacral wound developed drainage and a foul odor shortly before discharge. The resident was ultimately discharged to home without home health registered nursing care services and without education or instructions on how to care for the wound. The resident involved had multiple significant medical diagnoses, including diabetes mellitus, chronic congestive heart failure, permanent atrial fibrillation, atherosclerotic heart disease, chronic kidney disease, and peripheral vascular disease. Upon admission, the resident was assessed as having a moderate risk for pressure ulcers, with a Braden score of 14, and required partial to moderate assistance with mobility and transfers. The resident's care plan included preventative skin care measures such as the use of barrier cream, but documentation showed only general references to skin abnormalities and did not provide detailed wound assessments or evidence of consistent wound care interventions. Despite the presence of a chronic coccygeal wound and a physician's order for hydrophilic wound dressing, the facility did not document that wound care was provided as ordered. Additionally, when the wound developed drainage and a foul odor, there was no documentation that the physician was notified or that the care plan was updated. The resident was discharged home alone, without arrangements for skilled nursing follow-up or wound care education, contrary to facility policy and standard practice for wound management.
Deficiencies in PICC Line Management and Antibiotic Administration
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards, particularly concerning the management of peripherally inserted central catheter (PICC) lines. A resident admitted from the hospital with a PICC line did not have orders for PICC line maintenance or antibiotic administration, resulting in a two-day lapse in receiving necessary antibiotics for a bacterial infection. The staff did not verify the purpose of the PICC line or ensure continuity of care from the hospital, leading to a delay in treatment. Another resident was admitted with a PICC line for antibiotic treatment due to a kidney infection and osteomyelitis. However, there were no orders for PICC line maintenance or dressing changes. The resident's PICC line dressing was undated and appeared compromised, indicating a lack of proper care and maintenance. The staff failed to adhere to the facility's policy requiring orders for dressing changes and maintenance for all IVs and PICC lines. Interviews with the Director of Nursing and Registered Nurse revealed that the admitting nurse is responsible for verifying the purpose of the PICC line and obtaining necessary orders. Despite this, the facility did not ensure that the admitting nurse followed through with these responsibilities, resulting in deficiencies in care for residents with PICC lines. The facility's failure to maintain professional standards in managing PICC lines and ensuring continuity of care from the hospital led to these deficiencies.
Inadequate Supervision and Transfer Procedure Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow proper procedures for a resident who required assistance with transfers and mobility. The incident occurred when the resident, who had moderate cognitive impairment and required substantial assistance, was transferred to bed without the use of a sit-to-stand lift due to a dead battery. Despite the resident's insistence on being put to bed, the staff performed a two-person assist transfer, during which the resident's right foot was caught under the bed, resulting in a comminuted tibial plateau fracture. The facility's policy required the use of mechanical lifts for safe transfers, and the resident's care plan specified the need for a stand-up lift with two-person assistance. However, the staff deviated from this plan due to the lift's battery issue and the resident's insistence. The staff did not seek an alternative lift or battery from another floor, as suggested by the facility's Director of Nursing (DON). The incident was not immediately reported to the nurse, and the resident's injury was only discovered after the resident complained of pain and was subsequently sent to the emergency room for evaluation. Interviews with the staff involved revealed a lack of communication and adherence to the facility's policies. The Certified Nurse Assistants (CNAs) involved did not report the incident or the resident's pain to the Licensed Practical Nurse (LPN) on duty. The LPN and Staffing Coordinator were unaware of the injury until the resident was seen with a knee immobilizer after returning from the hospital. The facility's investigation highlighted the failure to follow the mechanical lift policy and the lack of proper assessment and reporting of the resident's condition.
Failure to Report Injury from Improper Transfer
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy by not reporting an incident involving a resident and two staff members in a timely manner. The incident occurred when the staff performed an improper transfer of the resident, resulting in a comminuted tibial plateau fracture. The facility's policy requires immediate reporting of such incidents, especially those resulting in serious bodily injury, to the appropriate state agency. However, there was no documentation indicating that the Department of Health and Senior Services (DHSS) was notified of the incident or injury. The resident involved had moderate cognitive impairment and required substantial to maximal assistance for transfers, as indicated in their care plan. The care plan specified the use of a stand-up lift with two-person assistance for transfers. On the day of the incident, the sit-to-stand lift's battery was not charged, and the resident, who was upset about waiting, was transferred manually by two CNAs. During the transfer, the resident's leg got caught, resulting in a fracture. The resident reported pain immediately after the transfer, but the staff did not recognize the severity of the injury at that time. Interviews with the staff involved revealed that the CNAs attempted to charge the lift's battery but proceeded with a manual transfer when it did not work. The resident expressed discomfort during the transfer, but the CNAs did not report the incident to the nurse immediately. The LPN was informed of the manual transfer but not of the injury. The facility's Administrator and DON acknowledged the injury but did not report it to DHSS, as they believed the incident was witnessed and not an unknown injury.
Failure to Provide Appropriate Immediate Discharge Letter
Penalty
Summary
The facility failed to provide an appropriate immediate discharge letter to a resident, which did not include the effective date of discharge, the specific location to where the resident was transferred, information on how to obtain an appeal form, assistance in completing the form, and submitting the appeal hearing request. Additionally, the letter did not inform the resident that they could return to the facility if an appeal was filed. The Long-Term Care Ombudsman's office address was incorrect, and no email address was listed. The resident, who had diagnoses including unspecified dementia, anxiety, and osteoarthritis, became increasingly agitated and aggressive after the facility physician discontinued their oxycodone prescription. The resident exhibited behaviors such as barricading their door, attempting to throw a chair at staff, and using a sharp object as a weapon. The facility physician ordered a psychiatric evaluation and transport to a psychiatric hospital. The resident was escorted out of the building by police and EMTs and was transported to the hospital. The facility's discharge form used for the resident's immediate discharge was found to be incomplete and did not include necessary information such as the effective date of discharge, the location to which the resident was discharged, and information on how to obtain and submit an appeal form. The Administrator stated that the location was not applicable because the resident was going to the hospital and that the appeal information was not applicable because it was not safe to keep the resident in the facility. The Administrator also did not know that the Ombudsman's office address had changed.
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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