Brent B Tinnin Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellington, Missouri.
- Location
- 220 Euel Polk Drive, Ellington, Missouri 63638
- CMS Provider Number
- 265472
- Inspections on file
- 15
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brent B Tinnin Manor during CMS and state inspections, most recent first.
The facility did not implement a QAPI Plan as required by their policy, which mandates a data-driven program to improve care outcomes and residents' quality of life. The Administrator, new to the role, confirmed that the program was not operational despite having the necessary policy and procedures in place.
The facility did not implement its QAA/QAPI program, failing to develop and document a plan of action to address quality deficiencies. The Administrator admitted the program was not operational, and the DON was unaware of PIPs documentation. This affected all 40 residents.
The facility did not conduct the required quarterly QAA/QAPI meetings with the necessary members. The policy outlined the need for a data-driven QAPI program, but it lacked details on required committee members. The Administrator, who began in January 2025, confirmed that the program was not yet operational, resulting in no committee meetings being held.
The facility failed to maintain a surety bond sufficient to cover residents' personal funds, as required by policy. The bond amount was $51,000, while the average monthly balance of residents' funds required a bond of at least $57,000. The Administrator noted that previous misappropriation of funds led to incorrect accounts, contributing to this deficiency.
The facility failed to document and obtain signatures for Medicare Non-Coverage Notices for three residents discharged from skilled services. The residents were not properly informed of potential non-coverage and financial liability, as required by facility policy.
The facility failed to conduct Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks prior to hiring four employees, contrary to their policies. Interviews confirmed that these checks should be completed before employment, but records showed they were either done late or not documented.
The facility failed to provide written notices of transfer or discharge to residents and/or their responsible parties, as required by policy. This deficiency was identified for five residents who were transferred to the hospital without documented notifications. The Administrator acknowledged the expectation for such notices to be given.
The facility failed to provide written information about the bed hold policy to residents or their representatives during hospital transfers. This issue affected six residents, with no documentation of the required notifications in their medical records, despite multiple hospital transfers.
A facility failed to complete a significant change MDS assessment within 14 days for a resident admitted to hospice services. Despite acknowledgment from the Administrator and MDS Coordinator that such assessments should be completed within 14 days of a significant change, the facility lacked a policy to ensure this was done, resulting in the deficiency.
A facility failed to provide a coordinated hospice care plan and necessary care for a resident, including turning, repositioning, and wound care. Another resident on valproic acid for epilepsy lacked monitoring of medication levels, with no recent lab results to ensure therapeutic levels. Facility policies on hospice care and lab monitoring were not followed.
A facility failed to obtain a physician's order for a CPAP machine and did not follow the continuous oxygen order for a resident with heart failure and malnutrition. Observations showed inconsistent oxygen use, and interviews with staff confirmed expectations for following physician's orders. The deficiency was identified through observations, interviews, and record reviews.
The facility failed to ensure that four NAs completed their training and certification within four months of hire, as required. Despite completing the training program, the NAs had not yet tested, and the facility's policy did not specify a timeframe for training completion. The Administrator acknowledged the lapse, attributing it to a lack of prioritization by the previous administration.
The facility failed to maintain proper infection control practices during catheter, wound, and incontinent care, with staff not adhering to hand hygiene protocols, failing to use enhanced barrier precautions, and sharing supplies between residents. Additionally, the facility did not correctly screen residents for tuberculosis as required by state regulations.
A facility failed to maintain an effective IPCP, including an antibiotic stewardship program, by not documenting appropriate indications for antibiotic use for a resident. The resident was prescribed doxycycline for a wound infection and Flagyl for diarrhea without necessary lab reports or findings. The DON confirmed the lack of a stool culture for Flagyl, and the Administrator acknowledged the failure to follow standard procedures.
The facility failed to document education and consent for influenza and pneumococcal vaccines for several residents. One resident received a pneumococcal vaccine despite refusing it, and others lacked documentation of education or consent for both vaccines. The facility's policies require documented education and consent, which were not followed.
The facility failed to document COVID-19 vaccination education and administration for three residents, despite their various medical conditions. The facility's policy required offering the vaccine and providing education on its benefits and risks, but there was no record of this being done for these residents. The DON stated that vaccinations were offered on admission, annually, or when available, with education and consent forms provided.
A resident's funds were misappropriated by the former Administrator (FADM) who used the resident's debit card for personal use, resulting in over $12,000 being misappropriated. The resident, who had cognitive impairments, was unaware of the unauthorized transactions. The FADM claimed the withdrawals were to prevent Medicaid from using the funds for the resident's bill, but no records supported this claim. The facility's policies were violated, and the police were notified, with the Prosecuting Attorney planning to prosecute the FADM.
A facility failed to investigate a resident-to-resident abuse allegation when an LPN did not report a physical altercation to the Administrator. A resident with cognitive impairment was hit by another resident after an argument, but the incident was only reported as a verbal altercation. The facility's policy requires reporting and investigating abuse, but the LPN's incomplete report led to a lack of proper investigation.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) Plan, which is essential for maintaining and improving care and services. The facility's policy, dated February 2020, mandates the development, implementation, and maintenance of a data-driven QAPI program focused on care outcomes and residents' quality of life. The policy also states that the facility's owner or governing board is responsible for the QAPI program, and the plan should be presented annually during the recertification survey. However, the facility did not have an implemented QAPI plan that outlined how they would identify and correct quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurements. During an interview, the Administrator, who started in January 2025, acknowledged that although the facility had the QAPI program shell and policy in place, the program was not yet operational.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility's policy, dated February 2020, required the development, implementation, and maintenance of an ongoing, facility-wide, data-driven QAPI program focused on care outcomes and residents' quality of life. However, the facility did not maintain the minimum required documentation for a QAPI plan or Performance Improvement Plans (PIPs). During interviews, the Administrator acknowledged that the QAA/QAPI program was not operational, and the Director of Nursing was unaware of the location of any PIPs documentation. This deficiency had the potential to affect all 40 residents in the facility.
Failure to Conduct Required QAA/QAPI Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance (QAA) and Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's policy, dated February 2020, outlined the development and maintenance of a data-driven QAPI program focused on care outcomes and quality of life for residents. The policy stated that the QAPI committee should meet monthly to review reports and monitor activities, but it did not specify the required committee members. Upon review, there was no documentation of the facility holding the minimum required quarterly QAA/QAPI meetings with the necessary members. During an interview, the Administrator, who started in January 2025, acknowledged that the QAA/QAPI program was not yet operational, and therefore, no committee meetings had been conducted.
Failure to Maintain Adequate Surety Bond for Residents' Funds
Penalty
Summary
The facility failed to maintain a surety bond for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months. The facility's policy on surety bonds, dated March 2021, outlines that a surety bond is an agreement to compensate residents for any loss of funds managed by the facility. However, the policy did not specify how the bond amount should be calculated. The facility's approved bond amount was $51,000, while the average monthly balance of residents' personal funds was $38,481.13. This average, when rounded to the nearest thousand and multiplied by one and one-half, indicated a required bond amount of at least $57,000, which the facility did not meet. During an interview, the Administrator acknowledged that the bond should be sufficient to cover the residents' funds. It was revealed that the previous administration had misappropriated money, leading to incorrect and unreconciled accounts. This mismanagement contributed to the facility's failure to maintain the appropriate surety bond amount, thereby not ensuring the security of residents' personal funds as required.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to properly document notification and obtain signatures for three residents regarding the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms. This deficiency was identified for three residents who were discharged from skilled services but remained in the facility or were discharged from the facility. The facility's policy requires that these forms be issued to residents or their representatives to inform them of potential non-coverage by Medicare and their financial liability, but this was not done. Resident #2 and Resident #36 were discharged from skilled services with remaining days in their benefit period and stayed in the facility, yet there was no documentation of the NOMNC and SNF ABN forms being issued. Resident #51 was discharged from skilled services and the facility, but the facility failed to notify the resident or their representative of the change in skilled services, and there was no documentation of the NOMNC form. Interviews with the Administrator and Social Service Designee confirmed the expectation that these forms should be provided with proper notifications and signatures in a timely manner, which did not occur in these cases.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the completion of Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks for new hires. Specifically, the facility did not conduct CBCs and EDL checks prior to the hire dates for Employees A and B, and failed to complete CBCs prior to the hire dates for Employees C and D. The facility's policy mandates that these checks be initiated within two days of an employment offer and completed before employment begins. However, the records show that these checks were either completed after the hire date or not documented at all. Interviews with the Human Resources staff and the Administrator confirmed that the CBC and EDL checks should be completed before employment and that EDL checks should be conducted quarterly thereafter. The HR staff, who was new to the position, acknowledged the oversight and was in the process of organizing the necessary documentation. The facility's failure to perform these checks as required by their policies represents a deficiency in their hiring and screening processes, potentially compromising resident safety.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written copy of the notice of transfer or discharge to residents and/or their responsible parties for five residents. This deficiency was identified through interviews and record reviews. The facility's policy on transfer or discharge, dated October 2022, outlines that a notice should be given as soon as practicable before the transfer or discharge, especially in cases where the health and safety of individuals in the facility are endangered or when an immediate transfer is required due to urgent medical needs. However, the facility did not adhere to this policy for the sampled residents. Specifically, the medical records of five residents showed multiple instances of transfers to the hospital without documented written notifications provided to the residents or their responsible parties. These residents were transferred on various dates, and in each case, there was no documentation of the written notification with the reason for the hospital transfer. During an interview, the Administrator acknowledged the expectation that residents and/or their representatives should receive a written copy of the notice of transfer or discharge, indicating a lapse in the facility's adherence to its own policy and regulatory requirements.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the facility's bed hold policy at the time of transfer to a hospital. This deficiency was identified for six residents out of a sample of six, indicating a systemic issue. The facility's policy, dated October 2022, requires that all residents or their representatives receive written information about the bed hold policy at least twice: once in the admission packet and again at the time of transfer, or within 24 hours if the transfer is an emergency. For each of the six residents, there was no documentation in their medical records that they or their representatives were informed in writing of the bed hold policy at the time of their hospital transfers. These residents experienced multiple transfers to the hospital, yet the facility consistently failed to provide the required written notification. During an interview, the Administrator acknowledged the expectation that residents and/or their representatives should be informed in writing of the bed hold policy before a transfer occurs.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days for a resident who was admitted to hospice services. The resident was admitted to hospice on 02/28/25, but there was no significant change MDS dated on or after this date. During interviews, both the Administrator and the MDS Coordinator acknowledged that a significant change MDS should be completed within 14 days of a significant change, such as admission to hospice. However, the facility did not provide a policy regarding the completion of significant change MDS assessments, leading to this deficiency.
Deficiencies in Hospice and Medication Management
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had a completed coordinated plan of care and received necessary care and services according to professional standards. The resident, who was admitted with diagnoses including protein calorie malnutrition and was at risk for pressure ulcers, had specific orders for turning and repositioning every two hours and daily wound care. However, observations revealed that the resident was left in the same position for extended periods, and wound dressings were not changed daily as ordered. Additionally, the hospice coordinated plan of care did not address the resident's wounds or Foley catheter care. Another resident, who had a diagnosis of epilepsy and was on valproic acid, did not have an order for monitoring valproic acid levels, which is crucial for maintaining therapeutic levels and preventing toxicity. The last documented valproic acid level was from over a year ago, and there was no follow-up to ensure that the levels were checked regularly. The resident's care plan included a focus on maintaining lab values within the therapeutic range, but this was not adhered to, as evidenced by the lack of recent lab results. The facility's policies on hospice care, lab and diagnostic test results, and prevention of pressure ulcers were not followed. The hospice care plan was not updated to reflect the resident's current needs, and there was a failure to monitor and document lab results for medication management. The facility also did not provide a policy regarding ordering labs for medication monitoring, which contributed to the oversight in managing the resident's valproic acid levels.
Failure to Obtain CPAP Order and Follow Oxygen Orders
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP machine and did not follow the physician's order for continuous oxygen for a resident. The resident, who was admitted with diagnoses of protein calorie malnutrition and heart failure, had an order for oxygen at 2 liters per minute via nasal cannula continuously. However, there was no order for a CPAP machine, and the resident's care plan did not address the use of a CPAP machine or its settings. Observations showed that the resident was not consistently wearing the oxygen as ordered, and the CPAP machine was used without a physician's order. Interviews with staff, including an LPN and the DON, revealed that they expected physician's orders to be followed, including continuous oxygen use and having an order for CPAP use with specified settings. The resident's oxygen saturation was found to be low at one point, and oxygen was then administered, which improved the saturation level. The facility's policy required a physician's order for oxygen administration, but there was no policy provided regarding CPAP use. The deficiency was identified through observations, interviews, and record reviews, indicating a failure to adhere to physician's orders and facility policies.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that four nurse aides (NAs) completed a nurse aide training program within four months of their employment. The facility's policy required newly hired NAs to attend an orientation program within the first five days of employment, but it did not specify a timeframe for completing the nurse aide training. NA B, NA D, NA F, and NA G were all found to have completed the nurse aide program but had not yet tested, exceeding the four-month requirement from their respective hire dates. Interviews with the NAs and the Director of Nursing revealed that the NAs were working in their positions without having completed the necessary certification within the required timeframe. The Administrator acknowledged the expectation for NAs to be certified within four months of hire and noted that the previous administration did not prioritize this requirement, resulting in the current situation where NAs were ready to test but had not yet done so.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices during catheter care, wound care, and incontinent care for several residents. Observations revealed that staff did not adhere to hand hygiene protocols, failed to use enhanced barrier precautions (EBP), and shared supplies between residents. For instance, a Certified Nursing Assistant (CNA) did not perform hand hygiene before and after providing catheter care to a resident, and shared wipes between residents without changing gloves or sanitizing hands. Similarly, a Licensed Practical Nurse (LPN) and another CNA did not follow proper hand hygiene and EBP protocols during wound care and incontinent care, leading to potential cross-contamination. The facility also failed to have dedicated disposable supply items for residents on EBP, as observed during care for residents with catheters and wounds. Supplies such as wound cleansers and tape were placed on unsanitized surfaces without a clean barrier and were not cleansed before being returned to the treatment cart. This practice was observed during wound care treatments for multiple residents, where shared supplies were used without proper sanitation, increasing the risk of infection. Additionally, the facility did not correctly screen residents for tuberculosis (TB) as required by state regulations. Medical records showed missing documentation of TB screenings for several residents, including the absence of admission TSTs and annual screenings. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that the expected infection control practices were not followed, and supplies should not be shared between residents, especially those on EBP.
Failure in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program, which is essential for monitoring antibiotic use and ensuring appropriate indications for their use. The deficiency was identified when the facility did not document an appropriate indication for the use of antibiotics for a resident who was being treated with doxycycline for a wound infection and Flagyl for diarrhea. The facility's policy on antibiotic stewardship, revised in December 2016, required antibiotics to be prescribed and administered under the guidance of the program, but the documentation was incomplete and lacked necessary lab reports or findings. Resident #19 was prescribed doxycycline for a wound infection and Flagyl for diarrhea, but there was no stool culture to justify the use of Flagyl. The resident had been taking Senna, a stool softener, which was stopped after diarrhea developed, and the diarrhea subsequently ceased. The Director of Nursing confirmed that the Flagyl order was given by the medical director without a stool culture, and the hospital records for the wound infection were not obtained. The Administrator acknowledged that the facility should have followed policy and procedures for the IPCP, including obtaining cultures and labs as expected with standard practice.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to document the provision of education regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines for several residents. Specifically, four residents did not have documented evidence of receiving pertinent information about the influenza vaccine, and three residents lacked documentation for the pneumococcal vaccine. Additionally, one resident was administered the pneumococcal vaccine despite having refused it. The facility's policies require that residents or their legal representatives receive and acknowledge this information, which was not adhered to in these cases. Resident #2's medical record showed that they were administered the influenza vaccine without documented consent or education, and received the pneumococcal vaccine after refusing it. Resident #4's record lacked documentation of education, consent, or administration for both vaccines. Resident #25's record showed no documentation of education, consent, or administration for both vaccines in 2024 and 2025. Resident #34 was administered the influenza vaccine without documented education or consent, and there was no documentation regarding the pneumococcal vaccine. The Director of Nursing stated that vaccinations were offered with accompanying education and consent forms, but this was not reflected in the records reviewed.
Failure to Document COVID-19 Vaccination Education and Administration
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered, administered, or refused by three residents out of five sampled residents. The facility's policy required that each resident be offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, with education provided regarding the benefits, risks, and potential side effects. However, for Residents #2, #4, and #34, there was no documentation in their medical records indicating that COVID-19 vaccination education was provided, nor was there any record of the vaccine being administered or refused. Resident #2 had multiple diagnoses, including metabolic encephalopathy, COPD, schizophrenia, hypertension, major depressive disorder, panic disorder, anxiety disorder, and hearing loss. Resident #4 had diagnoses of hematogenous osteomyelitis, heart failure, and dementia. Resident #34 had Alzheimer's disease, cerebral infarction, atrial fibrillation, and hypertension. Despite these conditions, there was no documentation of COVID-19 vaccination education or administration for these residents. The Director of Nursing stated that vaccinations were offered on admission, annually, or when provided by the facility, with education and consent forms given to residents or their representatives.
Misappropriation of Resident's Funds by Former Administrator
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property when the former Administrator (FADM) used the resident's bank debit card for personal use, resulting in a misappropriated amount exceeding $12,000. The incident occurred between November and December 2024, and the facility was notified of the missing funds in January 2025. The resident, who had some cognitive loss and diagnoses including Metabolic Encephalopathy, Schizophrenia, and Major Depressive Disorder, was unaware of the unauthorized withdrawals and purchases made using their account. The facility's investigation revealed that the FADM had used the resident's debit card to withdraw cash and make purchases, including medications sent to the FADM's address. The FADM claimed that the withdrawals were made to prevent Medicaid from requiring the funds to be used for the resident's bill, and that the money was given to the former bookkeeper to pay the resident's expenses. However, there were no records of these transactions being applied to the resident's billing or trust account, and the FADM admitted to accidentally using the resident's card for personal purchases. Interviews with the resident and facility staff confirmed that the resident did not give the FADM permission to use the card, and the facility's policies did not allow for such actions. The FADM's actions were not in line with the facility's Abuse Prevention Program and Management of Residents' Personal Funds policy, which emphasize safeguarding residents' funds and obtaining consent for any transactions. The police were notified, and the case was under investigation, with the Prosecuting Attorney intending to prosecute the FADM for the misappropriation.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents. A Licensed Practical Nurse (LPN) did not report the physical altercation between the residents to the Administrator for investigation. The facility's policy mandates the reporting and investigation of any abuse allegations, but in this case, the LPN only reported a verbal altercation, despite being informed of the physical nature of the incident by multiple staff members and the residents involved. Resident #1, who has diagnoses of congestive heart failure, anxiety, and schizophrenia, reported being hit by Resident #2 after an argument over the television volume. Resident #1, who is moderately cognitively impaired and requires maximum assistance with personal care, fell out of the wheelchair after being struck. Resident #2, who is cognitively intact and requires minimal assistance with activities of daily living, admitted to hitting Resident #1 and expressed no remorse for the action. Despite these admissions, there was no documentation of an abuse allegation investigation in either resident's medical record. The incident was initially reported as a verbal altercation by the LPN to the Director of Nurses and the Administrator, who was on vacation at the time. The Administrator delegated the investigation to a Registered Nurse (RN), who was informed by the LPN that there were no injuries and only an argument had occurred. As a result, the RN did not conduct a thorough investigation, believing the situation was resolved by relocating Resident #2 to another room. The failure to properly report and investigate the physical altercation represents a deficiency in the facility's adherence to its abuse and neglect policy.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
