Bluffs, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Missouri.
- Location
- 3105 Bluff Creek Drive, Columbia, Missouri 65201
- CMS Provider Number
- 265498
- Inspections on file
- 32
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Bluffs, The during CMS and state inspections, most recent first.
Staff failed to follow physician orders and required assessments for multiple residents. A resident returned from the hospital with unstageable foot pressure ulcers, but wound treatment orders were missing from the POS and dressings were not in place. Another resident’s heel wound care order was not followed because gauze was omitted during the dressing change. Staff also did not follow an order for wrist splints for a resident with ALS, and neurological checks after falls were incomplete for two residents, including one with a forehead hematoma and headache.
Meals Not Served According to Nutritionally Calculated Menus: Staff failed to serve lunch items in the portion sizes and menu items directed for residents on pureed, dental soft/mechanical soft, and regular diets on consecutive days. A dietary aide said the correct serving utensils could not be found and used what was available to start service on time, and the DFS and administrator stated meals are expected to be prepared and served according to the nutritionally calculated menus.
Hand Hygiene and Wet Dish Storage in Food Service Dietary staff were observed washing hands for only five seconds, handling food and meal-service items after touching their body, glasses, or facemask, and using gloves without consistent hand hygiene. A cook and multiple dietary aides handled food and silverware after inadequate handwashing, and one aide said he/she was too busy to wash hands between tasks. The DFS stated staff are trained on hand hygiene, but quarterly audits had not been completed since 05/28/25. Staff also stacked sanitized trays, plates, and insulated plate holders while they were still wet instead of allowing them to air dry before storage. The DFS and administrator stated clean dishes should be air-dried before being put away.
The facility failed to maintain its IPCP, including annual review of policies and procedures and documentation of infection control incidents. Staff did not consistently use EBP or proper hand hygiene and glove changes during wound care and resident care for residents with wounds and indwelling catheters, and catheter tubing was observed touching the floor. The facility also did not complete required two-step TB screening correctly for four employees, including missing documentation, testing before hire, and improper spacing between steps.
Failure to Track and Trend Antibiotic Use: Facility staff did not implement an ASP with antibiotic use protocols or a system to monitor and trend antibiotic use. The IP said he/she was responsible for the program but had only recently started in the role and had not completed tracking and trending for the current month, while the DON and administrator acknowledged that antibiotics and infections were not being tracked on paper or through graphs daily or weekly, despite the facility policy calling for tracking, reporting, and performance evaluation of antibiotic use and infection data.
The facility failed to offer and document COVID-19 vaccine education, consent, or refusal for four sampled residents and three sampled staff members. Record review showed no evidence that the residents or staff were educated about the vaccine, offered an updated booster, or documented as refusing it. The DON, administrator, and infection preventionist stated the vaccine had not been offered for about a year and that documentation of staff vaccination or education could not be found.
Failure to preserve resident dignity during mealtime assistance: staff were observed standing over multiple residents while feeding them, including residents with cognitive impairment and upper-extremity limitations who required varying levels of eating assistance. A CNA fed one resident without conversation, and staff interviews confirmed that feeding residents while standing was viewed as disrespectful, intimidating, and not dignified; the DON, RN, LPNs, and Administrator all stated staff should sit beside residents at eye level during meals.
Inconsistent code status documentation was found for two residents. One resident had DNR on the EMR face sheet and care plan, but a physician order for Full Code and a red door dot; the other had DNR on the EMR face sheet and care plan, but a physician order for Full Code, a green door dot, and an Outside the Hospital DNR form in the binder. Staff interviews confirmed they relied on the EMR, door dots, and binder for code status information, and the SSD was responsible for updating the dots and admission paperwork.
A resident with impaired cognition and significant weight loss repeatedly refused ordered Med Pass 2.0 and protein shakes, but staff did not notify the MD or RD despite documenting many refusals over several months. In a separate case, another resident with diabetes and hyperlipidemia did not receive a brand-specific protein shake as ordered, with the supplement documented unavailable many times and staff unsure whether the nurse contacted the family, pharmacy, or MD when the resident ran out.
Failure to Screen New Hires Through CNA Registry: The facility failed to complete CNA Registry checks for five of ten new employees, including a DFS, two RSAs, a dietary aide, and an LPN. Personnel records lacked documentation of the required checks, and the HR Director stated checks were not done for non-CNA positions because he/she did not know they were necessary. The DON and administrator stated all staff should be checked through the CNA Registry.
Care plans were not updated to reflect changed resident needs for multiple residents. A resident with heel pressure ulcers, a resident with repeated behaviors and refusals, a resident refusing ordered wrist splints, a resident whose diet had changed to regular, a resident with significant weight loss and antipsychotic use, and a resident with a toe wound and EBP needs all had care plans that did not match current assessments, orders, or documented conditions. Staff interviews showed the MDS/Care Plan Coordinator was expected to update the plans, but the needed revisions were not made.
Expired medications and supplies, along with opened undated insulin pens, were found in medication carts and storage rooms in multiple areas of the facility. Observations identified expired naloxone, eye drops, syringes, needles, prochlorperazine, hemorrhoidal ointment, respiratory medications, and treatment supplies, while staff interviews showed unclear responsibility for expiration checks and inconsistent monitoring by central supply, nurses, CMTs, and the DON.
A facility failed to keep medications and ointments secured in a memory care unit when staff left Nystatin powder, wound dressing, and barrier ointments out in an unlocked whirlpool bathroom and also left ointments in a resident’s bathroom. Staff said the items should have been returned to the med cart, and the DON and administrator stated they should be kept locked when not in use, especially for residents with dementia who wander.
An LPN, unfamiliar with the unit, administered insulin to a resident who was not prescribed the medication due to relying on an incorrect report sheet for bed assignments. The resident, who was not diabetic, experienced hypoglycemia and required hospital admission for monitoring and treatment. The error was discovered after the resident questioned the LPN, leading to immediate assessment and intervention.
A resident with a history of spinal surgeries suffered a compression fracture after being improperly lowered into a shower chair using a mechanical lift. The incident occurred when two staff members failed to control the lift's descent, causing immediate back pain. The resident was transported to the hospital and did not return to the facility.
A long-term care facility failed to follow infection control protocols, using a single insulin pen for multiple residents and neglecting proper hand hygiene during care. Staff also did not adhere to Enhanced Barrier Precautions for residents with wounds or medical devices, risking pathogen transmission.
The facility failed to maintain a clean and homelike environment, with observations of disrepair and cleanliness issues in resident rooms, such as ripped floors, chipped paint, and black grout. Interviews revealed a breakdown in the reporting and repair process, as staff were unaware of specific issues, indicating a failure in communication and follow-through on maintenance needs.
The facility failed to provide written notice to residents or their representatives for hospital transfers, affecting four residents. Interviews revealed no formal process for such notifications, and staff acknowledged the absence of a policy. The Regional Nurse Consultant described the expected procedure, which was not followed.
The facility failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers. Two residents were transferred without receiving this information, and staff interviews revealed a lack of awareness and process for such notifications. The facility administrator acknowledged the issue and planned to implement a new process.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. A resident with dementia had no specific interventions for managing behaviors, while another with impaired vision and arthritis lacked positioning guidance. A resident on hospice care did not have updated care plans, and another's activity preferences were not addressed. Staff relied on verbal reports, and care plans were not consistently updated.
The report identifies deficiencies in a facility's documentation and medication administration. A resident's neurological checks were not documented after a fall, and another resident had multiple medication patches due to improper documentation and communication. Additionally, several residents' medication orders lacked indications for use, contrary to facility policy. These issues highlight lapses in adherence to care protocols and communication among staff.
Facility staff failed to safely transfer two residents using a mechanical lift, did not use footrests while propelling two residents in wheelchairs, and left medications unsecured on treatment carts. The DON confirmed that staff should follow procedures to ensure resident safety during transfers and that medications should be secured at all times.
Facility staff failed to maintain hot food temperatures for residents, serving meals at temperatures below 120°F. Observations showed scrambled eggs, oatmeal, and other foods were served cold, with residents expressing dissatisfaction. Staff interviews revealed inconsistent monitoring practices and varying opinions on appropriate serving temperatures. The dietary manager and aides were noted as responsible for checking temperatures, but delays in serving hall trays contributed to the issue.
A resident with Alzheimer's and other conditions fell and sustained a broken hip, but the LPN on duty failed to notify the family, physician, or facility administrator as required. The family only learned of the fall after taking the resident to the hospital due to leg pain. Interviews confirmed the lapse in communication and documentation.
Facility staff failed to follow their Abuse and Neglect policy by not investigating an allegation of misappropriation of property and not contacting law enforcement within the required timeframe. A resident with moderate cognitive impairment had an electronic device reported missing by a family member. The administrator did not report the incident to the police until five days later, as he was unaware of the requirement. Staff interviews indicated that they were directed to report such incidents to the charge nurse or Director of Nursing, but the necessary actions were not taken.
A facility failed to report a missing electronic device for a resident to DHSS within the required timeframe. The resident, with moderate cognitive impairment, had their device reported missing by a family member. The administrator delayed reporting to DHSS until it was suspected the device was stolen, contrary to the facility's policy requiring immediate reporting of such incidents.
Facility staff failed to perform proper hand hygiene and sanitize thermometers, leading to potential cross-contamination. Observations showed lapses in handwashing between glove changes and improper thermometer cleaning. Additionally, the kitchen was not maintained in a clean state, with dirt and debris observed on floors and appliances. Staff interviews revealed awareness of hygiene protocols but noted oversight and lack of clear cleaning responsibilities.
Failure to Follow Physician Orders and Complete Required Assessments
Penalty
Summary
Staff failed to maintain professional standards of practice when they did not ensure wound care orders were in place for a resident with two unstageable pressure ulcers on the right lateral foot after return from the hospital. The resident’s discharge MDS showed cognitive impairment, substantial to maximal assistance with bathing, dressing, hygiene, and footwear, and the presence of unhealed pressure ulcers. The POS did not contain a treatment order for the right lateral foot wounds, and observation showed the resident had the pressure ulcers without dressings in place. An LPN stated the resident returned from the hospital at the end of the prior week, the wound clinic had provided new orders, and the orders had not yet been entered into the computer. The DON and administrator stated they expected staff to follow physician orders and were not aware the treatment orders were missing. Staff also failed to follow a wound care order for another resident with unstageable pressure ulcers to both heels. The resident’s MDS showed moderate cognitive impairment, dependence for several ADLs, and two unstageable pressure ulcers. The POS ordered cleansing both heels, applying betadine, covering with dry four-by-fours, wrapping with kerlix, and securing with tape. During observation, an LPN completed the dressing change but did not place dry gauze over the heels before wrapping them with kerlix. The LPN stated there should have been sterile gauze between the pressure ulcers and the kerlix, realized the omission after wrapping the heels, and did not remove the dressings to correct it. The DON and administrator stated staff were expected to follow physician orders. Staff further failed to follow an order for wrist splints for a resident with ALS, generalized muscle weakness, impaired upper extremity function, and dependence for all mobility. The resident’s POS ordered wrist splints on in the morning and off in the evening, but the TAR documented repeated refusals, while the care plan did not address the splints or refusals. Multiple observations showed the resident without the splints during the day, and the splints were found left on papers or on a printer in the resident’s room. The resident stated staff did not ask about wearing the splints and said he/she had not refused them and would like to wear them. Staff interviews reflected confusion about when the splints should be worn, and the DON stated he/she was not sure if the resident was supposed to be wearing them. Staff also failed to complete neurological assessments after falls for two residents. The facility’s neurological assessment flowsheet directed checks at set intervals after a fall, but one resident with severe cognitive impairment and a history of falls had unwitnessed falls on three occasions, and the record did not contain all required neurological checks for those events. Another resident with cognitive intactness and a history of non-injury falls was found face down on the floor with a forehead hematoma, hand bruise, thigh bruise, and headache, but the neurological assessment flow sheet did not contain all required shift assessments over the documented period. Staff interviews stated neurological checks were required after unwitnessed falls or falls with head involvement, and the DON and administrator stated the charge nurse was responsible for completing them.
Meals Not Served According to Nutritionally Calculated Menus
Penalty
Summary
The facility failed to serve food in accordance with the nutritionally calculated menus for residents on pureed, dental soft/mechanical soft, and regular diets during lunch meal service on two consecutive days. On 01/28/26, the menu directed pureed residents to receive pureed barbequed pork, mashed potatoes with thick gravy, pureed spinach, and a pureed dinner roll with margarine, but staff served smaller portions of the pork, mashed potatoes, and spinach and did not prepare, serve, or offer the pureed dinner roll with margarine. The same day, the menu directed dental soft/mechanical soft residents to receive ground barbequed pork with sauce and a buttered soft dinner roll, but staff served a smaller portion of the pork and did not prepare, serve, or offer the dinner roll. Regular diet residents were also not served the dinner roll and margarine as directed. On 01/29/26, the menu directed pureed residents to receive pureed beef tips with gravy and pureed rice pilaf, but staff served smaller portions of both items. Dental soft/mechanical soft residents were directed to receive rice pilaf and chopped buttered carrots, but staff served smaller portions of both items. Regular diet residents were directed to receive beef tips with gravy and rice pilaf, but staff served less than the menu directed. During interview, the dietary aide said the correct serving utensils could not be found and used what was available because meal service needed to start on time, and the Director of Food Services and administrator stated staff are expected to serve meals according to the nutritionally calculated menus and portion sizes listed for each diet type.
Hand Hygiene and Dish Drying Failures in Food Service
Penalty
Summary
Facility staff failed to perform hand hygiene using approved techniques during food preparation and service. On 01/28/26, a Dietary Aide scrubbed his/her hands with soap for five seconds, then put on gloves, retrieved cheese from the walk-in refrigerator, delivered it to the cook, and handled a cart of glasses for meal service. Later that morning, another Dietary Aide adjusted glasses and a mask with bare hands and then wrapped silverware in napkins without performing hand hygiene. The same aide was also observed picking something from his/her ear, adjusting glasses, pulling down a facemask to take a drink, and then continuing to handle silverware without washing hands. A cook and another Dietary Aide were also observed washing hands for only five seconds before handling food or serving residents. During interview, the Dietary Aide stated he/she had worked in the kitchen for two to three weeks, had been trained on hand hygiene, and knew hands should be washed between tasks and after touching the body, glasses, or facemask, but said he/she did not wash because he/she got too busy. Another Dietary Aide stated staff had not trained him/her on proper hand hygiene procedures, though he/she said hands should be scrubbed long enough to sing the alphabet song twice. The Director of Food Services stated staff are trained on sanitation and infection control upon hire and during routine in-services, and that hands should be washed when entering the kitchen, before handling food, before and after glove use, and after touching anything dirty, including the body, glasses, and facemask. The director also stated quarterly hand hygiene audits were his/her responsibility but had not been completed since 05/28/25. Facility staff also failed to allow sanitized dishes to air dry before stacking and storing them. Observations showed plastic service trays, insulated plate holders, plates, and insulated dome plate covers stacked together while still wet by the steamtable, on a service cart by the dish storage rack, and on a utility cart from the mechanical dishwashing station. The Director of Food Services stated clean dishes should be air-dried before being put away and that staff are trained on this requirement. The administrator stated there was no policy located related to dish washing and storage, but clean dishes should be air-dried before storage and the Director of Food Services was responsible to monitor dish washing and storage daily when on duty.
Infection Prevention Program, EBP, Catheter Care, and TB Screening Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The report states the facility did not develop and review the infection prevention and control program, policies, and procedures annually, did not provide a policy regarding the IPCP, and did not have documentation that a program was in place to record infection control incidents. During interview, the DON said updates were looked at as issues came up but the IPCP had not been reviewed annually, and the Administrator said he/she believed the DON and IP were reviewing policies annually but was not aware that this was not being done. The facility also failed to implement enhanced barrier precautions and infection control practices during care for three residents with wounds and/or indwelling catheters. Resident #7 had moderate cognitive impairment, unhealed pressure ulcers, and an indwelling catheter. Observations showed the resident’s room did not have EBP signs posted, CNA N assisted with showering without placing a barrier on the wheelchair foot pedals before the resident rested bare heels on them, and LPN I performed wound care without donning a gown. The LPN also picked up the resident’s heel from a wheelchair foot pedal that had a wet spot and did not clean the foot pedal with an approved cleaner. Resident #103 had severe cognitive impairment, was dependent for all self-care and mobility, and had a wound on the right great toe. Observations showed no EBP signs posted in the room, and LPN I performed wound care without a gown, did not change gloves before applying skin prep, and did not perform hand hygiene before putting on new gloves to place the dressing. Resident #123 had cognitive impairment, substantial to maximal assistance needs, unhealed pressure ulcers, and an indwelling catheter. Observations showed no EBP signs posted, and staff assisted the resident to bed and with linens without wearing gowns or performing hand hygiene at key points, including after removing gloves and before leaving the room. The facility further failed to maintain sanitary conditions during catheter care and catheter tubing management. Resident #8 had severe cognitive impairment, partial/moderate assistance for personal hygiene, an indwelling catheter, and a care plan noting increased infection risk due to a Foley catheter and a positive urine culture for MRSA. During observed catheter care, CNA A touched the bed, clothing, belt, brief, and trash can and did not change gloves before providing catheter care. For Resident #7, observations showed the catheter tubing touched or dragged on the ground while the resident was in a wheelchair and in the dining room. Staff interviews confirmed that catheter tubing should not drag or rest on the floor because of infection control concerns. The facility also failed to complete required employee TB screening for four staff members. The Director of Food Services’ file did not contain documentation of a first or second step TB test. CMT BB’s file showed the two TB steps were completed too close together. CNA B’s file showed the first step was not completed prior to hire and the two steps were not spaced appropriately. CNA X’s file showed the first step was not administered prior to hire. The facility’s policy required newly hired employees to be screened for TB after an employment offer but before duty assignment, with the second step administered within one to two weeks after the first step was read.
Failure to Track and Trend Antibiotic Use
Penalty
Summary
Facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility’s policy stated that the Antibiotic Stewardship Program was intended to optimize treatment of infections while reducing unnecessary laboratory tests and antibiotic use, and that the program would track and report antibiotic use, infection rates, and microbiology data. The policy also stated that performance would be evaluated by monitoring antibiotic-associated adverse drug events, multidrug-resistant organisms, C. difficile infections, and trends in high-risk antibiotic use. Review of the program showed staff did not have a process in place to track and trend antibiotic usage. The IP stated he/she was responsible for maintaining the program and said he/she reviewed infections and antibiotics at the end of the month, completed a tracking form, and color coded information on a facility map, but also stated he/she had just started in the role in December and had not started tracking and trending for January. The DON stated he/she thought the program was being completed monthly, acknowledged that antibiotics and infections were not being tracked on paper and through graphs daily or weekly, and said information was discussed in morning meetings and IDT meetings. The administrator stated the IP was responsible for maintaining the program, was new to the position, and was unaware the program was not being completed monthly; the administrator also stated the expectation was that the ASP be reviewed daily or weekly.
Failure to Offer and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to ensure residents were offered the COVID-19 vaccine and that education, signed consent, or refusal documentation was obtained for four sampled residents. Review of the records for Residents #7, #19, #21, and #28 showed no documentation that they received education about the benefits and risks of the COVID-19 vaccine, no record that they refused the vaccine, and no documentation of an updated booster. The facility policy stated that COVID-19 vaccinations would be offered to all residents unless medically contraindicated, already immunized during the time period, or the individual refused the vaccine. The facility also failed to document COVID-19 vaccine education, offering, or refusal for three sampled staff members: the Director of Food Services, CNA B, and RSA C. The DON stated the facility had not given or offered the COVID-19 vaccine to residents or staff in about a year, explaining that the vaccine had not been available for a period of time and that the person who ran the COVID clinics had been out on maternity leave. The administrator stated residents and staff had been up to date until the newest version came out and said it had been about a year since the vaccine was offered, adding that he/she had been told the vaccine was unavailable. The infection preventionist also stated he/she could not find documentation of staff COVID-19 vaccinations or education and was not aware of the vaccine being offered to staff in the last six months.
Failure to Preserve Resident Dignity During Mealtime Assistance
Penalty
Summary
Facility staff failed to maintain resident dignity during mealtime when staff stood over residents while assisting them with eating. Observation and record review showed Resident #58 had severe cognitive impairment, ROM impairment to one upper extremity, and required set-up assistance with eating; during lunch, a CNA stood over the resident, picked up the resident’s silverware, offered bites of food, and continued feeding the resident without engaging in conversation. Resident #78 had severe cognitive impairment, ROM impairment to one upper extremity, and required supervision or touch assistance with eating; staff were observed standing over the resident while feeding on two separate occasions. Resident #34 had moderate cognitive impairment, ROM impairment to one upper extremity, and required set-up assistance with eating; a CNA stood while feeding the resident for the entire time assistance was provided. Resident #19 was cognitively intact, had impairment of one upper extremity, and required substantial/maximal assistance for eating; a CNA stood over the resident with food on a fork and did not talk to the resident before placing the food in the resident’s mouth. During interviews, multiple staff members stated that staff should sit beside residents and not stand over them while feeding, describing the practice as disrespectful, intimidating, rude, and not dignified. The RN, LPNs, DON, and Administrator all stated that staff should be at the resident’s level during feeding, and one CNA stated he/she had not been told not to stand while feeding residents and did so to help more than one resident at a time.
Inconsistent Resident Code Status Documentation
Penalty
Summary
Facility staff failed to document code status consistently for two residents. Resident #2 was admitted with a DNR code status on the EMR face sheet, but the physician order sheet dated 12/2025 showed a signed Full Code order, while the care plan dated 12/2025 still documented DNR. Observation of the resident’s door showed a red dot indicating DNR, and the facility’s code status binder did not contain the resident’s code status for staff to use when the resident left the building. Resident #100 had a similar inconsistency. The EMR face sheet showed DNR on admission, the physician order sheet dated 10/2025 showed a signed Full Code order, and the care plan dated 10/2025 documented DNR. Observation of the resident’s door showed a green dot indicating Full Code, while the facility’s code status binder showed an Outside the Hospital DNR form on file. Interviews with CNA staff, an LPN, SSD, DON, and the Administrator confirmed that staff relied on the door dots, EMR ribbon, and binder for code status information, and that the SSD was responsible for placing the dots and updating code status information.
Failure to Report Repeated Supplement Refusals and Provide Ordered Protein Shakes
Penalty
Summary
Facility staff failed to notify the physician or registered dietician when one resident repeatedly refused prescribed nutritional supplements. Resident #44 had impaired cognition and was assessed with significant weight loss on the quarterly MDS. The care plan documented weight loss, Med Pass 2.0 60 ml TID, protein shakes BID, and encouragement of oral intake. The POS showed the supplements had been ordered for months, but the MAR documented repeated refusals of Med Pass 2.0 and protein shakes across November 2025, December 2025, and January 2026. During interviews, the CMT said the resident had been refusing both supplements for a long time and that refusals should have been communicated to nursing, the physician, and the RD, but he/she could not recall when or to whom it was reported. The DM said he/she was not aware the resident consistently refused the protein shakes and had not been informed by nursing so the RD could be notified. The LPN and DON both stated that repeated refusals should be reported to the physician and RD after a few days of refusal, but neither was aware the resident had been consistently refusing the supplements. Facility staff also failed to obtain a prescribed brand-specific protein shake in a timely manner for another resident. Resident #61 had diagnoses including hyperlipidemia and diabetes mellitus, and the care plan called for a therapeutic diet. The POS ordered a brand-specific protein shake BID at breakfast and lunch, but the MAR documented it was unavailable 42 out of 62 times. Observations showed the shake was not provided on multiple occasions, and the resident stated the facility did not provide the type of shake ordered and that his/her son supplied them. Staff interviews showed the CMT had informed the nurse the resident was out of shakes, but it was unclear whether the nurse contacted the family, pharmacy, or physician, and the DON and Administrator stated staff were responsible for following the order and ensuring the resident had the protein shakes.
Failure to Screen New Hires Through CNA Registry
Penalty
Summary
The facility failed to screen five of ten new employees through the CNA Registry before employment to determine whether they had any indicators related to abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property. The facility census was 115. Review of the facility’s Abuse & Neglect policy dated 05/31/24 showed the facility would not employ individuals with a finding entered on the Missouri CNA Registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property, and that it would report knowledge of court actions indicating unfitness for service as a nurse aide or other facility staff. Personnel record review showed no documentation of CNA Registry checks for the Director of Food Services, RSA D, RSA C, Dietary Aide CC, and LPN FF. The Human Resource Director stated he/she could not provide CNA Registry checks for the listed staff and said he/she did not run CNA Registry checks on positions that were not CNAs because he/she did not know it was necessary. The DON stated he/she had just found out all staff should be run through the CNA Registry and said the Human Resource Director was responsible for the checks on new hires. The administrator stated the Human Resource Director handled the background work and that everyone should be checked on the CNA Registry.
Care Plans Not Updated for Changed Resident Needs
Penalty
Summary
The facility failed to review and revise care plans to reflect changes in residents’ needs for six sampled residents. The report states the facility also failed to provide a policy directing staff when to review or revise care plans. Staff interviews showed the MDS/Care Plan Coordinator was generally responsible for updating care plans, while other nurses and CNAs understood that significant changes, wounds, refusals, splints, weight loss, and behavior changes should be reflected in the care plan. For Resident #7, a significant change MDS dated 01/12/26 identified moderate cognitive impairment, one or more unhealed pressure ulcers, and two unstageable pressure ulcers. Progress notes dated 12/02/25 documented the resident was seen by wound clinic for two unstageable pressure ulcers to both heels, but the revised care plan dated 01/20/26 did not include the bilateral heel pressure ulcers. The MDS/Care Plan Coordinator stated wounds should be on the care plan and was unsure why this resident’s pressure ulcers were not included. For Resident #8, nursing notes documented behaviors, refusal of care, medication refusal, irritability, delusional/paranoid statements, and verbal aggression toward staff across multiple entries, but the care plan dated 11/27/26 did not include aggressive behaviors or refusals of care. For Resident #19, the resident had repeated refusals of ordered wrist splints documented on the TAR throughout January 2026, and observations showed the resident without the splints on multiple occasions; however, the care plan dated 01/15/26 did not include splint use or refusals. For Resident #61, the care plan dated 03/23/25 still identified a therapeutic diet for diabetes, GERD, hypertension, and hyperlipemia even though the resident’s records showed a regular diet and the resident stated he/she was on a regular diet. For Resident #78, the quarterly MDS showed severe cognitive impairment, antipsychotic use, and significant weight loss, but the care plan dated 12/23/25 did not address antipsychotic medication monitoring or the weight loss. For Resident #103, the quarterly MDS identified severe cognitive impairment, dependence for care and mobility, and risk for pressure ulcers, and the POS included daily treatment for a right great toe wound, but the care plan dated 11/21/25 did not include the toe wound or enhanced barrier precautions.
Expired Medications and Supplies Found in Medication Carts and Storage Rooms
Penalty
Summary
Facility staff failed to ensure medications and supplies were stored in a safe and effective manner when expired items and undated opened medications were found in medication carts and storage rooms. The facility policy stated stock medications should be checked at least monthly for expiration dates, rotated so the oldest stock is in front, and expired medications destroyed. During observations, expired naloxone spray and an expired eye drop bottle were found in the Cherry hall medication cart, and the Elm hall nurse's medication cart contained multiple expired supplies and medications, including an insulin safety syringe, a Luer-Lok tip syringe, a safety needle, prochlorperazine suppositories, and a hemorrhoidal ointment tube, along with opened insulin pens that were not dated. Additional observations in the Elm hall medication storage room showed expired and opened supplies, including a box of bismuth subsalicylate tablets, a sterile foam swab, a straight tip self-catheter, specimen collection swabs with vials, and a disposable syringe needle. In the Cherry hall medication storage room, expired treatment kits and respiratory medications were also present, including a wound dressing change kit, a hypodermoclysis kit, albuterol solution vials, budesonide inhalation suspension packets, and ipratropium bromide/albuterol sulfate inhalation solution vials. Staff interviews showed confusion about who was responsible for checking expiration dates, with some staff stating central supply handled the task, others stating nurses or CMTs were responsible, and one RN stating he/she did not know when carts and storage rooms should be checked. The Central Supply Coordinator stated he/she checked treatment supplies only every six months or so and said a pharmacy person checked medication carts monthly, while the DON stated central supply was supposed to remove expired supplies and medications from all medication rooms and that CMTs and nurse managers were also responsible for maintaining and auditing the carts. The administrator stated he/she expected the CMT or nurse to remove expired over-the-counter medications and supplies, but that it was ultimately his/her responsibility to ensure it was done.
Unsecured Medications and Ointments Left Accessible in Memory Care Areas
Penalty
Summary
The facility failed to ensure the residents’ environment remained free of accident hazards when staff left medications and ointments unattended in the memory care unit whirlpool bathroom and in one resident’s bathroom. Observation showed the whirlpool bathroom door was unlocked and propped open, with Nystatin topical powder labeled with a resident’s name, Triad hydrophilic wound dressing, Calmoseptine ointment, and A&D ointment sitting out on the counter. Staff interviews confirmed the items were being left out after use and that they should have been returned to the medication carts, while the DON and administrator stated medications and ointments should be kept locked when not in use, especially on the locked memory care unit where residents wander and have cognitive impairment. Resident #62 had severe cognitive impairment and a diagnosis of dementia, and the physician orders included checking the wander guard each shift. Observations showed the resident wore a wander guard and wandered into the whirlpool bathroom, while the resident’s bathroom contained three tubes of A&D ointment and Selan plus Zinc oxide barrier cream on separate observations. Staff stated the resident was not cognitive and wandered, and both the DON and administrator said the ointments and medications should not have been left where the resident could access them.
Medication Error: Insulin Administered to Non-Diabetic Resident
Penalty
Summary
Facility staff failed to ensure residents were free from significant medication errors when an LPN administered another resident's insulin to a resident who was not prescribed insulin or any blood sugar medications. The error occurred because the LPN, unfamiliar with the unit, relied on a report sheet that incorrectly listed bed assignments, leading to the administration of 40 units of Basaglar insulin to the wrong resident. The resident who received the insulin was cognitively intact and had diagnoses including iron deficiency, atrial fibrillation, hypertension, and renal failure, but was not diabetic and had no orders for insulin. After receiving the insulin, the resident questioned the LPN about being diabetic, prompting the LPN to realize the mistake by cross-checking the report sheet and the medication administration record. The resident subsequently experienced hypoglycemia, with blood sugar levels dropping and requiring frequent monitoring, snacks, and eventually transfer to the hospital for further observation and treatment. The incident was documented in progress notes and confirmed through interviews with the resident, LPN, and Director of Nursing.
Improper Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
Facility staff failed to provide a proper mechanical lift transfer for a resident, resulting in a compression fracture of the resident's spine. The incident occurred when two staff members were assisting the resident with a mechanical lift transfer to a shower chair. The lift's knob released too quickly, causing the resident to be abruptly lowered into the chair. This improper handling led to the resident experiencing immediate back pain, prompting the staff to call an ambulance for hospital transport. The resident, who was cognitively intact and required substantial assistance for transfers, had a history of spinal surgeries, including a laminectomy and discectomy earlier in the year. The hospital records confirmed a new L1-L2 compression fracture following the incident. Interviews with facility staff revealed that the resident was upset and in pain after the transfer, and the resident declined a nurse assessment before being taken to the hospital. The resident did not return to the facility after the incident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to standard universal infection control precautions, as evidenced by the use of a single insulin pen on three residents, potentially risking the transmission of bloodborne and bacterial pathogens. The incident occurred when an LPN, unable to access the medication cart due to locked keys, used an emergency medication kit's insulin pen for multiple residents, changing only the needles between uses. This action was contrary to the CDC's guidelines and the manufacturer's safety information, which explicitly state that insulin pens should never be shared between patients. Additionally, the facility staff did not follow proper hand hygiene practices during perineal and wound care for several residents. Observations revealed that staff members failed to perform hand hygiene after glove removal and before engaging in further resident care activities. This lapse in protocol was noted during the care of residents who required assistance with personal hygiene and wound care, where staff neglected to wash hands or change gloves appropriately, increasing the risk of cross-contamination. The facility also did not comply with Enhanced Barrier Precautions (EBP) for residents with wounds, feeding tubes, or indwelling catheters. Staff were observed not wearing gowns during high-contact care activities, despite the presence of EBP signage indicating the need for such precautions. Interviews with staff revealed a lack of understanding and inconsistent application of EBP, which are critical for preventing the spread of multidrug-resistant organisms. These deficiencies highlight significant gaps in the facility's infection prevention and control practices.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility staff failed to maintain a clean, homelike, and comfortable environment for residents, as evidenced by multiple observations of disrepair and cleanliness issues in resident rooms. Specific observations included a ripped bathroom floor and stained floor trim in one room, gouged and chipped paint on walls in another, scuff marks, missing drywall, and a black substance on bathroom grout in several rooms. These issues were noted during observations conducted over two days, indicating a lack of timely maintenance and repair. Interviews with facility staff, including housekeepers, maintenance aides, certified nurse aides, registered nurses, and the Maintenance Director, revealed a breakdown in the reporting and repair process. Staff members indicated that they were supposed to report maintenance issues to their supervisors, who would then create work orders for the maintenance department. However, the Maintenance Director was unaware of the specific issues in the rooms observed, suggesting a failure in communication and follow-through on reported maintenance needs. The Director of Nursing confirmed that staff training included the work order policy, but the observed deficiencies indicate that the policy was not effectively implemented or followed.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice to residents or their representatives regarding transfers to the hospital for four sampled residents. The facility's policies did not include a procedure for hospital transfers, leading to a lack of documentation for notifications. Resident #19 was transferred to the hospital twice, on 05/25/24 and 07/29/24, without documented written notification to the resident or their representative. Similarly, Resident #48 was transferred to the Emergency Department on 10/9/24 with no written notification documented. Resident #69 was transferred on 06/05/24, and during an interview, the resident confirmed no paperwork was issued regarding the transfer. Resident #115 experienced two transfers, on 09/11/24 and 09/20/24, with no written notifications documented. Interviews with facility staff revealed a lack of a formal process for providing written notifications of hospital transfers. The administrative assistant confirmed the absence of a written notification process, while the Regional Nurse Consultant outlined the expected procedure, which includes providing a notice of transfer to the resident and having them sign it before leaving. This documentation should be scanned into the resident's electronic medical record. The Director of Nursing acknowledged that planned discharge paperwork is handled by Social Services, but there was no policy for written notifications for hospital transfers.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital. This deficiency was identified for two out of three sampled residents, with a facility census of 117. The facility's policies did not include a procedure for notifying residents or their representatives about the bed hold policy during hospital transfers. Specifically, the medical records for two residents showed that they were transferred to the hospital on multiple occasions, but there was no documentation indicating that they or their representatives were informed in writing about the bed hold policy. Interviews with facility staff revealed a lack of awareness and process regarding the written notification of the bed hold policy. The administrative assistant confirmed the absence of a process for providing written notification, while the Regional Nurse Consultant outlined the expected procedure, which was not being followed. Registered Nurse E and the Director of Nursing also indicated a lack of knowledge about the requirement for written bed hold paperwork. The facility administrator acknowledged the issue and mentioned that a new process for hospital transfers would be implemented soon.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop comprehensive care plans with resident-specific interventions for five residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. For Resident #45, who was cognitively impaired with a diagnosis of dementia, the care plan lacked direction for managing verbal and physical behaviors, as well as attempts to leave the secured unit. Despite documented incidents of agitation and aggression, the care plan did not provide specific interventions, and staff were unsure of the care plan's contents regarding these behaviors. Resident #49, who was cognitively intact but had severely impaired vision and arthritis, had a care plan that did not address positioning in the recliner, despite the resident's expressed difficulty sitting up due to back pain. Observations showed the resident consistently positioned almost flat in the recliner, which was not addressed in the care plan. Similarly, Resident #56's care plan did not include directions for the use of bed rails, despite a physician's order and the resident's use of them for mobility. For Resident #108, who was on hospice care, the care plan was not updated to include hospice services, despite the resident's status change. The MDS Coordinator acknowledged the oversight, indicating a lack of timely updates. Resident #111's care plan did not include activity preferences, despite the resident's severe cognitive impairment and family reports of the resident's need to be active. Interviews with staff revealed a reliance on verbal reports and care sheets, with care plans not being consistently updated or detailed, contributing to the deficiencies observed.
Documentation and Medication Administration Deficiencies
Penalty
Summary
The report identifies several deficiencies in the documentation and administration of care within the facility. One significant issue involved the failure to document neurological checks for a resident who experienced a fall. The facility's policy requires that neurological checks be conducted for all residents who have unwitnessed falls or falls with head involvement. However, in the case of Resident #119, the Licensed Practical Nurse (LPN) did not document the necessary neurological checks after the resident was found on the floor. This lapse was attributed to the LPN being responsible for two halls, as noted by the Director of Nursing (DON). Another deficiency was observed in the administration of medication patches for a resident diagnosed with Alzheimer's and Parkinson's disease. The facility's policy mandates that staff document the removal of old patches and the placement of new ones. However, for Resident #48, there was no documentation of patch removal or the location of new patches over a specified period. This oversight led to multiple patches being found on the resident, which was not reported to the charge nurse, indicating a breakdown in communication and adherence to medication administration protocols. Additionally, the report highlights the failure to document indications for medication use for several residents. The facility's policy requires that all medication orders include the name and indication for use. However, for seven residents, the Physician Order Sheets lacked this critical information. Interviews with staff, including a Registered Nurse (RN) and the DON, revealed that there was an awareness of the issue, but it had not been adequately addressed. This deficiency in documentation could lead to confusion regarding the purpose of medications and potential medication errors.
Deficiencies in Resident Transfers, Wheelchair Safety, and Medication Security
Penalty
Summary
The facility staff failed to transfer two residents using a mechanical lift in a manner that prevents accidents. For Resident #26, two CNAs attached the resident's sling to the lift and raised the resident without guiding them, which is against the facility's policy that requires one staff member to guide the resident during the transfer. Similarly, for Resident #81, the CNAs did not maintain the lift's legs in the wide-open position during the transfer, which is necessary for stability, especially in small rooms. The Director of Nursing confirmed that the staff should have followed the correct procedures to ensure resident safety during transfers. The facility also failed to safely propel two residents in wheelchairs. Resident #50 was moved by a Dietary Aid without footrests, causing the resident's foot to bounce on the floor. Similarly, Resident #24 was propelled by a staff assistant without footrests, leading the resident to pick up and put down their feet during the movement. Both staff members acknowledged the unsafe practice and the potential for injury, and the DON confirmed that staff are educated to use footrests to prevent accidents. Additionally, the facility did not properly secure medications on two treatment carts. A Certified Medication Technician left insulin pens and other medications unsecured and unattended on top of a medication cart, which was accessible to residents. Another observation showed a treatment cart left unlocked and unattended in a dining area. The DON stated that medications should be secured at all times to prevent resident access, and staff are educated on the importance of locking medication carts.
Failure to Maintain Proper Food Temperatures for Residents
Penalty
Summary
Facility staff failed to maintain the temperature of hot food at or above 120 degrees Fahrenheit for four residents during meal service. Observations revealed that scrambled eggs, oatmeal, Cream of Wheat, tomato soup, pulled pork, corn, and rice were served at temperatures ranging from 76 to 92 degrees Fahrenheit, which is below the required temperature. Residents reported that their food was often cold, particularly during breakfast, and expressed dissatisfaction with the quality of their meals. The facility's policy emphasizes the importance of serving nutritious and appetizing meals, but the current practice does not align with this policy. Interviews with staff, including CNAs, dietary aides, the dietary manager, RNs, and the director of nursing, highlighted a lack of consistent monitoring of food temperatures at the time of service. Staff members provided varying opinions on the appropriate serving temperature, ranging from 130 to 165 degrees Fahrenheit. The dietary manager indicated that aides are responsible for checking temperatures once the hall tray cart leaves the kitchen. However, it was noted that hall trays are often served after dining room residents, leading to delays and cold food. The director of nursing and the administrator acknowledged the issue, with the administrator stating that the dietary manager is responsible for food service, but ultimately, the administrator is accountable.
Failure to Notify Family and Physician After Resident's Fall
Penalty
Summary
Facility staff failed to notify a resident's physician and representative in a timely manner following a fall that resulted in a major injury. The facility's policy requires that family members, physicians, and residents be informed of significant changes in condition, including falls and injuries. However, after the resident experienced a fall, the responsible LPN did not document the incident or notify the necessary parties, including the resident's family, physician, or facility administrator. This lapse in communication was discovered when the resident's family took them to the hospital due to leg pain, where they were diagnosed with a broken hip. The resident involved was assessed as dependent for transfers, toileting, and hygiene, with diagnoses including Alzheimer's disease, dementia with psychosis, anxiety, insomnia, and peripheral vertigo. Despite these conditions, the LPN on duty did not report the fall or the resident's refusal to be assessed for hip pain. The family was only informed of the fall after the resident was admitted to the hospital. Interviews with facility staff, including the RN and DON, confirmed that the fall was not reported or documented as required by the facility's policy.
Failure to Report Misappropriation of Property in a Timely Manner
Penalty
Summary
The facility staff failed to adhere to their Abuse and Neglect policy in investigating an allegation of misappropriation of property and did not contact local law enforcement within the required timeframe. The policy mandates that all allegations of abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property, be thoroughly investigated and reported immediately to the administrator and the Missouri Department of Health and Senior Services (DHSS) within 24 hours if the events do not involve abuse or result in serious bodily injury. Additionally, any reasonable suspicion of a crime against a resident must be reported to law enforcement within two hours if it results in serious bodily injury or within 24 hours if it does not. However, in this case, the facility did not contact the police until five days after the allegation was made. The incident involved a resident with moderate cognitive impairment whose electronic device was reported missing by a family member. The family member emailed the administrator about the missing device, but the administrator did not report it to the police, as he was unaware of the requirement. The administrator only notified DHSS after determining the item was potentially stolen, based on information from the resident's family that the device had been deactivated and reactivated by someone else. Interviews with facility staff, including a CNA and an LPN, revealed that staff were directed to report abuse, including misappropriation of property, to the charge nurse or the Director of Nursing, but the required actions were not taken in this case.
Failure to Timely Report Missing Resident Property
Penalty
Summary
The facility failed to report a missing electronic device for a resident to the Department of Health and Senior Services (DHSS) within the required timeframe. According to the facility's policy on abuse and neglect, any alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property, must be reported immediately to the Administrator and DHSS. The policy specifies that such reports should be made within two hours if the allegation involves abuse or results in serious bodily injury, and within twenty-four hours if it does not. In this case, the resident's family member informed the administrator via email that the electronic device was missing, but the notification to DHSS was delayed until two days later. The resident involved was assessed with moderate cognitive impairment according to their Quarterly Minimum Data Set (MDS). The administrator acknowledged that staff are directed to report abuse, including misappropriation of property, immediately. However, the administrator did not report the missing device to the police, as they were unaware of the requirement to do so. The notification to DHSS was only made after the administrator determined that the device could potentially have been stolen, following information from the resident's family member that the device had been deactivated and reactivated by someone else.
Deficiencies in Hand Hygiene, Thermometer Sanitization, and Kitchen Cleanliness
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols, which is crucial in preventing the spread of infection. Observations revealed that dietary server C did not wash hands between glove changes and proceeded to handle food and utensils without sanitizing. Similarly, cook A neglected to perform hand hygiene after handling trash and before cleaning kitchen equipment. Interviews with the staff, including dietary server C, cook A, and the kitchen supervisor, confirmed that they were aware of the hand hygiene requirements but failed to comply due to oversight and being busy. The facility lacked a specific policy for hand hygiene or glove changes, contributing to these lapses. Additionally, the facility staff did not properly sanitize thermometers used for checking food temperatures, which poses a risk of cross-contamination. Dietary server C and cook A were observed using thermometers without sanitizing them before and after use. The kitchen supervisor and administrator acknowledged that staff are instructed to sanitize thermometers with alcohol wipes, but this practice was not consistently followed. The absence of a policy on cleaning thermometers further exacerbated the issue. The facility also failed to maintain cleanliness in the kitchen, with observations noting a buildup of dirt and debris on floors and appliances. The kitchen floor had a white substance under the ice machine, and the walls and equipment were covered with dirt and dried substances. Interviews with kitchen staff, including cook A and dietary server C, indicated a lack of clarity on cleaning responsibilities and schedules. The kitchen supervisor, who was new to the position, admitted difficulty in managing kitchen duties and acknowledged the absence of a deep cleaning chart, which contributed to the unsanitary conditions.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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