Buffalo Prairie Center For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo, Missouri.
- Location
- 631 West Main Street, Buffalo, Missouri 65622
- CMS Provider Number
- 265471
- Inspections on file
- 29
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Buffalo Prairie Center For Rehab And Healthcare during CMS and state inspections, most recent first.
Staff failed to honor a full-code resident’s wishes for CPR when an LPN discontinued resuscitation efforts before EMS arrived. The resident, who had COPD, prior intracerebral hemorrhage, and kidney cancer, was documented as full code on the face sheet, care plan, and physician orders. When the resident was found unresponsive with fluid from the nose and mouth and no pulse, the LPN verified full-code status, directed staff to call 911, and began chest compressions. As fluid and vomit were observed, the LPN rolled the resident to the side, then stopped CPR, stating the resident had aspirated and could not be resuscitated, and did not proceed with suction. Other staff and later-arriving EMS and the coroner confirmed that CPR had been stopped prior to EMS arrival, despite facility expectations that CPR for a full-code resident be continued until EMS assumes care.
Staff failed to ensure accurate administration and documentation of an antibiotic and steroid regimen for a resident with COPD and pneumonia. The physician ordered cefdinir for a defined seven-day course and a tapering prednisone schedule, but the MAR showed cefdinir documented for ten days while a medication card still contained unused doses, and progress notes indicated the drug was unavailable on some of the days it was charted as given. Prednisone doses for two ordered periods were not documented as administered, and an unopened prednisone card was found despite active orders. Multiple CMTs, LPNs, the DON, and the Medical Director acknowledged that medications should be given and documented as ordered, that blanks on the MAR indicate doses were not given, and that unavailability should be recorded, yet there were unexplained discrepancies between orders, MAR entries, and actual medication availability.
A resident with a history of spina bifida, UTIs, pyelonephritis, sepsis, urostomy, and a brain shunt was not care planned for shunt monitoring, and no shunt-related orders or staff training were documented. The resident experienced frequent headaches and neck/shoulder pain, with repeated PRN Tramadol and Acetaminophen use and several episodes of unrelieved pain, yet progress notes often lacked pain characteristics and there was no consistent evidence of MD notification when pain persisted. The resident’s WBCs were elevated, but follow-up CBC orders and timely MD notification were not documented, and urine output records were inconsistent despite reports from CNAs of decreasing output and dark, tea-colored urine. Staff interviews described the resident’s worsening pain, confusion, hallucinations, low BP, puffy face, distended abdomen, and dark urine, while management initially discussed treating in-house before the resident was eventually sent to the hospital, where hydrocephalus requiring shunt replacement and urosepsis with septic shock were diagnosed.
A resident with paralysis and high risk for skin breakdown developed extensive pressure-related wounds to the coccyx, sacrum, and bilateral buttocks after staff failed to consistently assess, document, and obtain MD orders for a new coccyx wound, did not update the care plan, and did not ensure use of pressure-reducing devices despite MDS-identified need. Initial documentation lacked wound measurements, detailed descriptions, and timely MD notification, and subsequent worsening with open, weeping, foul-smelling areas was reported by staff as resembling “hamburger meat” with odor and blackened areas. Wound orders were inconsistently entered on the POS, weekly skin and wound assessments were missed or incompletely documented, and staff interviews revealed confusion about responsibility and frequency for wound monitoring and documentation after the ADON who previously managed wound assessments was no longer in that role.
Surveyors identified a failure to maintain a sanitary, orderly, and comfortable environment, with multiple halls and rooms containing dried stains, accumulated debris, overflowing trashcans, strong urine and bowel odors, and trash and food crumbs on floors and under beds. A resident reported routinely cleaning their own room and having soiled bedding left on the floor for days, while another resident noted delays in trash removal and better cleanliness on weekdays when housekeeping was present. Staff, including CNAs, a COTA, and a housekeeper, described the building as dirty at the start of shifts, especially after weekends, with trash left by night and weekend staff, shower rooms cluttered with linens and clothing, frequent overflowing trashcans, and uncertainty about housekeeping coverage and leadership, despite existing policies requiring routine and cycle cleaning of all resident-use areas.
A resident with neuromuscular bladder dysfunction and an indwelling catheter did not have catheter care addressed in the care plan or physician orders, despite facility policy requiring catheter care every shift. During observed care, CNAs used a single washcloth on the inner thighs, did not change gloves or perform hand hygiene between perineal and bowel care tasks, failed to retract the foreskin, and cleansed the catheter tubing from the distal end toward the meatus instead of away from the body. Staff interviews, including with the CNA, another CNA, the DON, and the Administrator, confirmed that catheter tubing was expected to be cleansed away from the body to prevent infections, which was not followed in this instance.
Surveyors identified that staff failed to follow the facility’s infection control policies during peri-care for a resident with an indwelling catheter and during wound care for a resident with lower extremity ulcers. During catheter and peri-care, CNAs moved from cleaning bowel incontinence to handling clean briefs, the catheter, the drainage bag, the toilet, and the sink without changing gloves or performing hand hygiene, and did not disinfect surfaces touched with soiled gloves. In a separate wound treatment, an LPN began care without hand hygiene, placed soiled scissors on a clean barrier next to sterile supplies, repeatedly reached into bulk gauze and handled clean supplies with contaminated gloves, then later used those previously contaminated supplies to dress the wound and returned contaminated bulk items to the treatment cart. Interviews with CNAs, the DON, and the Administrator confirmed that these actions were inconsistent with facility expectations for hand hygiene, glove changes, and cleaning of reusable items.
The facility failed to maintain an effective pest control program when multiple flies were repeatedly observed on and around several residents and in their rooms, despite an existing pest control policy and contracted services. One cognitively impaired resident was seen in bed with numerous flies crawling on their hands, legs, body, and linens, while other cognitively intact residents reported that flies were always present, were bothersome, and required them or family to swat and kill multiple flies during visits. Staff, including an RN, reported that flies had recently become widespread after warmer weather, that the issue had been reported to the Administrator and DON, and that flies posed infection control concerns, while the DON, Maintenance Supervisor, and Administrator each described expectations that staff report fly problems to maintenance and rely on pest control monitoring and bug lights.
A resident with severe cognitive impairment and behavioral symptoms was slapped by a staff member during care, and the incident was not reported to facility management or the state agency within the required two-hour timeframe. Staff interviews confirmed knowledge of immediate reporting requirements, but the delay in reporting resulted in noncompliance with abuse prevention and reporting policies.
A facility failed to conduct a timely and thorough investigation into an allegation of physical abuse involving a resident with severe cognitive impairment and behavioral symptoms. The investigation relied only on statements from the two nurse aides involved, without interviewing other staff or residents, and lacked documentation of immediate protective measures for all residents during the investigation.
Staff failed to consistently document and administer physician-ordered medications for multiple residents, resulting in numerous undocumented doses of critical medications such as insulin, antipsychotics, pain relievers, and antibiotics. Residents with complex medical needs reported missed or late medications, and staff interviews revealed that documentation was often incomplete due to workload. Leadership was unaware of the extent of these lapses, and required documentation and notification procedures were not followed.
Three cognitively intact residents with chronic conditions, including diabetes and GERD, consistently received meals that were not served at appropriate temperatures, with food items measured below the required 135°F. Staff and dietary personnel acknowledged receiving complaints about cold food, and a test tray confirmed substandard temperatures. There was inconsistent understanding and application of the facility's food temperature policy among staff.
Facility staff did not complete an admission MDS assessment within the required timeframe for a resident with multiple complex diagnoses, and there was no documented policy on MDS assessments. Interviews with staff confirmed the assessment was not completed as required.
A resident with multiple complex diagnoses was moved to a locked memory care unit after several behavioral incidents involving theft of food and beverages. Staff did not complete a significant change MDS assessment following the transfer, and the care plan was not updated to address the behaviors that led to the move. Facility staff confirmed the required assessment was not completed.
A resident was transferred to the hospital after experiencing chest tightness, tachycardia, and fever, but staff did not complete the required discharge with return anticipated MDS or the readmission MDS within the mandated timeframe. Interviews revealed that the MDS Coordinator was new to the role and the facility lacked a policy for MDS assessments, resulting in the deficiency.
Staff did not complete a baseline care plan within 48 hours for a newly admitted resident with multiple complex diagnoses, contrary to facility policy. Documentation was missing, and staff interviews revealed confusion about the required timeframe for baseline care plan completion.
Staff failed to complete a comprehensive care plan for a resident with multiple complex diagnoses after admission, and did not update another resident's care plan to address repeated behavioral incidents and a subsequent move to a locked unit. Interviews with the SSD, MDS Coordinator, Administrator, and DON confirmed that care plans were not completed or updated as required by facility policy.
The facility did not pay overdue invoices for a portable generator, leading to the removal of the generator after repeated warnings from the service provider. Observations confirmed the absence of an operational generator on site, and interviews revealed that facility leadership was unaware of the outstanding debt due to invoices being sent directly to ownership. The facility lacked a policy on timely payments to service providers.
Two nurse aides provided direct care without completing required CNA training and certification within the mandated 120-day period. Personnel files lacked documentation of certification, and facility leadership acknowledged lapses in oversight and compliance with CNA training requirements.
A resident with Alzheimer's disease, chronic kidney disease, and BPH was left in a Broda chair for over two hours with visible urine incontinence, despite staff passing by and facility policy requiring checks every two hours and as needed. The resident was not checked or changed until prompted by a surveyor, resulting in saturated clothing and chair. Staff interviews revealed uncertainty about care routines and acknowledged the resident should have been attended to sooner.
The facility was cited for ineffective and inefficient use of resources, as identified in a survey. The citation pertains to the overall management and resource utilization practices, without specific details on actions or individuals involved.
The facility failed to maintain adequate RN and DON staffing, leading to the DON working as a charge nurse or CNA, which hindered her ability to perform essential duties. This resulted in a lack of effective antibiotic stewardship and significant medication errors, including missed warfarin doses and unavailable medications.
The facility failed to employ a qualified dietary manager for its food and nutrition services department. The current dietary manager lacked necessary certifications and training, such as being a certified dietary manager or having an associate's degree in food service management. The administrator was unaware of these requirements, leading to a deficiency in staffing qualifications.
The facility failed to maintain an effective infection control program, particularly in preventing Legionella growth and ensuring proper hand hygiene. The facility lacked a Legionella risk assessment and did not monitor water conditions. Staff, including the DON and CMTs, were observed not performing hand hygiene during medication passes, despite being aware of its importance.
The facility failed to maintain an effective antibiotic stewardship program, lacking a current and ongoing log for residents with active infections. Despite having a policy in place, the facility only provided a printout of antibiotic prescriptions for September, with no further tracking documentation. Interviews with the DON revealed no residents on antibiotics, no documented tracking measures, and no outcome surveillance related to antibiotic use. The Administrator expected adherence to guidelines, but the deficiency indicates a lack of proper implementation.
The facility failed to provide adequate pressure ulcer care and documentation for two residents, leading to deficiencies in wound management. Staff did not consistently assess and document pressure ulcers, and treatment orders were not entered into the system. Interviews revealed that the former wound nurse did not enter treatment orders, resulting in a lack of documented care.
The facility failed to manage oxygen equipment per standards for two residents with COPD, resulting in undated or outdated nasal cannulas and tubing. Despite orders for weekly changes, observations showed equipment unchanged since mid-month. Staff interviews revealed confusion over responsibilities, contributing to the deficiency.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed medications and document substitute orders. One resident with multiple fractures did not receive morphine or Percocet due to pharmacy delays, while another resident with COPD and cancer faced similar issues with Tylenol and oxycodone. Staff interviews revealed systemic problems with medication procurement and documentation, leading to prolonged pain for the residents.
A LTC facility failed to maintain a medication error rate below 5%, resulting in a 12.82% error rate. Errors included administering incorrect medication forms and dosages, and improper techniques for g-tube medication administration. A resident received a tablet instead of liquid medication, another received incorrect dosages, and a third had medications improperly combined for g-tube administration.
The facility failed to store controlled substances securely and left medication carts unlocked and unattended. Controlled substances for two residents were not stored under two locks, and medication carts containing narcotics were left unlocked in areas accessible to residents. Staff interviews confirmed the expectation for secure storage, but observations showed non-compliance with these protocols.
A resident with chronic conditions was found without accessible water on multiple occasions, despite care plan requirements for thickened liquids. Observations showed the resident was visibly thirsty, and staff interviews revealed confusion about hydration protocols. The facility failed to ensure water was accessible during regular rounds.
A facility failed to conduct the required PASARR Level 1 screening for a resident with mental disorders before admission. The resident, diagnosed with major depressive disorder, bipolar disorder, and psychosis, exhibited symptoms such as delusions and socially inappropriate behavior. Despite these indicators, the PASARR was not completed, as confirmed by the Central Office Medical Review Unit. The Social Services Designee was responsible for the PASARR but only completed it if the hospital had not done so.
A resident with schizophrenia and major depressive disorder did not receive their prescribed escitalopram oxalate on multiple occasions due to the medication's unavailability. Despite facility policies requiring timely reordering and follow-up with the pharmacy, staff failed to ensure the medication was available, leading to missed doses. The DON and other staff were not consistently aware of the medication's status, and the facility's tracking system was not reviewed daily, contributing to the deficiency.
A resident with thrombophilia missed three doses of warfarin sodium due to unavailability, as documented by a CMT. The medication was on hold but should have been restarted, and staff failed to notify the DON or physician about the missed doses. The facility's policy required immediate reporting of such discrepancies, which was not followed, resulting in a significant medication error.
The facility failed to maintain complete medical records for two residents transferred to the hospital and later returned. Documentation lacked details such as the reason for transfer, time, and physician notifications. Interviews with staff revealed expectations for obtaining physician orders and documenting all relevant details, which were not followed.
CPR Discontinued Early for Full-Code Resident Prior to EMS Arrival
Penalty
Summary
Facility staff failed to ensure a full-code resident’s wishes regarding cardiopulmonary resuscitation (CPR) were honored when CPR was discontinued prior to EMS arrival. The resident had diagnoses including COPD with acute exacerbation, nontraumatic intracerebral hemorrhage, and malignant neoplasm of the kidney, and was documented as a full code on the face sheet, care plan, and physician orders. The care plan and facility CPR policy required that staff provide basic life support, including CPR, in accordance with the resident’s advance directives and continue CPR prior to EMS arrival if the resident did not show obvious signs of clinical death. On the morning of the incident, an LPN entered the resident’s room and observed the resident sitting on the side of the bed with a cup in hand, appearing as if preparing to get a drink. After tending to the roommate and returning, the LPN noted the resident was unresponsive, with fluid coming from the nose and mouth, and no palpable pulse. The LPN asked another staff member to verify the resident’s code status, was informed the resident was full code, and directed staff to call 911. The LPN initiated chest compressions, during which fluid continued to come from the resident’s mouth and nose. The LPN rolled the resident to the side to allow more fluid to drain, observed vomit on the bedding, and then rolled the resident back and continued compressions. The LPN reported the resident felt room temperature and that the chest felt soft and mushy during compressions. According to written statements and interviews, the LPN stopped CPR after determining the resident had aspirated and believing resuscitation was not possible, despite the resident’s full-code status and without EMS on scene. CNA and CMT staff present confirmed that CPR was started and then discontinued, and that the LPN declined to continue compressions or use suction, stating the resident had aspirated too much and that nothing more could be done. EMS personnel and the county coroner later arrived and found the resident with dependent back lividity and no CPR in progress; both stated that CPR should have been continued until EMS arrival. Multiple staff interviews, including CNAs, CMTs, LPNs, the DON, the Administrator, and the Medical Director, consistently described that facility practice and expectations were to initiate CPR for full-code residents and continue until EMS arrival or a physician pronouncement, indicating that in this case staff actions did not follow the resident’s documented wishes or the facility’s stated process.
Failure to Accurately Administer and Document Antibiotic and Steroid Therapy
Penalty
Summary
Facility staff failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident with COPD, nontraumatic intracerebral hemorrhage, and kidney cancer. The resident had moderate cognitive impairment, shortness of breath with exertion, at rest, and when lying flat, and was receiving oxygen therapy. On one occasion, the resident was found with an oxygen saturation of 78% on six liters via nasal cannula, with bilateral wheezing and rhonchi and diminished lung sounds at the bases. Staff documented that the resident was on prednisone until a specified date and had completed a course of cefdinir for pneumonia, and the physician was notified for further recommendations. Subsequent physician documentation showed that, due to non-resolving pneumonia, the resident was to continue cefdinir 300 mg PO BID for seven days and start prednisone 40 mg PO daily for five days, then decrease by 5 mg every five days until discontinued. The February Physician Order Sheet reflected an order for cefdinir 300 mg PO BID for seven days, and prednisone 40 mg PO daily for five days followed by prednisone 35 mg PO daily for five days. However, the February MAR showed cefdinir documented as administered twice daily for ten days, three days longer than ordered, and staff progress notes later documented that cefdinir was not available on two of those days. The MAR also showed no documentation of prednisone administration for the ordered periods, with only a single prednisone dose documented on a later date. Observation of the medication storage revealed an unopened package of prednisone 35 mg, ordered once daily for five days, and a cefdinir medication card dated earlier in the month with three of fourteen capsules remaining, despite MAR documentation indicating administration beyond the seven-day order. Interviews with the Medical Director confirmed that all medications should be administered and documented as prescribed, and that he would presume medications were not given if not documented. Multiple CMTs and LPNs stated that medications should be administered as ordered, that blanks on the MAR indicate medications were not administered, and that unavailability or refusals should be documented on the MAR and in progress notes. Staff also reported issues with medication availability related to a pharmacy change. The DON and Administrator both stated that medications should be administered as prescribed, that there should be no blanks on the MAR, and that medications should not remain on the MAR past the stop date, but they were unaware of why cefdinir was documented past the stop date, why doses remained, or why prednisone doses were not documented or administered as ordered.
Failure to Monitor Brain Shunt, Manage Pain, and Respond to UTI/Sepsis Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, resident preferences, and goals for a resident with complex medical needs, including a brain shunt, urostomy, history of UTIs, acute pyelonephritis, and sepsis. The resident’s face sheet and care plan did not include a diagnosis of a brain shunt, and there were no physician orders or care plan interventions for monitoring the shunt. Staff were not documented as being trained or informed about shunt care, and there was no systematic monitoring of head, neck, or shunt-related symptoms despite frequent complaints of headaches and pain. The facility’s pain management policy required evaluation of pain upon admission and with changes in condition, use of appropriate pain assessment tools, and development and revision of interventions, but documentation repeatedly lacked characteristics of the pain, including location and quality, and did not reflect consistent reassessment or escalation when pain was not relieved. The facility also failed to effectively address increasing pain in the resident’s head, neck, and shoulder areas and did not consistently notify the physician of unrelieved or escalating pain. MAR and progress note reviews showed numerous PRN administrations of Tramadol and Acetaminophen for pain scores ranging from 3 to 9 out of 10, including generalized body aching, back pain, and neck and shoulder pain, with multiple instances where pain remained at 5–7 out of 10 after medication. Progress notes frequently omitted the characteristics or location of the pain, and when pain was not relieved, there was no documentation that the physician was notified. Interviews with CNAs indicated the resident complained of daily headaches, described the head as "blowing up or exploding," cried from pain, and reported pain at the shunt site, yet these complaints were only reported verbally to nurses and not reflected in detailed clinical documentation or care plan revisions. A roommate reported the resident’s head appeared swollen and that the resident became confused several days before hospital transfer. In addition, the facility failed to timely recognize and respond to signs of possible UTI and sepsis, and did not complete or follow up on ordered labs for elevated WBCs. The resident had a history of UTIs, kidney infections, and sepsis, and a WBC of 14.4 was documented in December, followed by a WBC of 16.8 on 01/06/26. There was no prompt physician notification documented for the increasing WBC, and although a physician note later referenced leukocytosis with a plan to recheck the CBC, no new lab orders appeared on the POS and no follow-up lab documentation was found. The care plan required monitoring and reporting of signs of kidney infection and sepsis, including no output, deepening urine color, and other symptoms, but MARs showed inconsistent urine output documentation, with multiple days lacking any recorded output. CNAs reported decreasing urine output from several bag drainings per shift to sometimes once per day, and described dark, tea-colored, and burnt orange urine, as well as the resident’s decreased eating, confusion, hallucinations, low blood pressure, puffy face, and distended abdomen. Although these findings were eventually reported to nursing staff, there was a delay in sending the resident to the hospital, and management initially discussed treating the resident in-house and attributing confusion to new medication. The resident was ultimately transferred to the hospital, where documentation showed diagnoses of hydrocephalus requiring shunt removal/replacement and urosepsis with septic shock, with the resident intubated and sedated in the ICU and a WBC of 43.7.
Failure to Assess, Treat, and Document Pressure Ulcers and Prevent Worsening Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive services consistent with professional standards for a resident who was at risk for skin breakdown and later developed extensive pressure-related wounds. The resident had spina bifida with paralysis, neuromuscular bladder dysfunction, a history of UTIs and sepsis, and required substantial to maximum assistance with ADLs and mobility. The resident’s MDS indicated intact cognition, no existing pressure ulcers, risk for pressure ulcers, and a need for pressure-reducing devices for bed and chair. The care plan directed staff to assess, record, and monitor wound healing as ordered, measure wounds, document wound bed and perimeter, report changes to the MD, and follow facility policies for prevention and treatment of skin breakdown. On a weekly skin assessment dated early in the month, staff documented no open areas and no pressure-reducing devices in use, with only skin discoloration on the left buttock. A few days later, the DON documented being called to the resident’s room for an open coccyx area and applied a foam dressing, but there was no documented full wound description, no measurements, and no documentation of MD notification or treatment orders for this new area. The POS for that month did not contain orders for pressure-reducing devices or for treatment of the new coccyx wound, and no new skin assessment was completed after the earlier weekly assessment. The care plan was not updated to reflect the new coccyx wound, and progress notes for the following week contained no wound assessments or documentation related to the open area. Later in the month, a nurse documented that the resident’s coccyx, sacrum, and bilateral buttocks were open, red, irritated, and weeping serous drainage, and that the MD was notified and wound care orders were received and applied. However, this note still lacked wound measurements and a detailed wound description, and the new wound orders were not entered on the POS. A physician progress note documented ulcerations to the coccyx, sacrum, and bilateral buttocks and the need for a wheelchair cushion for pressure reduction, but no order for a pressure-reducing cushion was documented on the POS. A subsequent wound assessment recorded multiple open areas on both buttocks with specific measurements and daily dressing changes, but again without detailed descriptive characteristics. Shortly thereafter, the resident was hospitalized, and a surgery consult described excoriated sacral skin, necrotic-appearing tissue near the anus, and foul-smelling purulent drainage. Interviews with CNAs, nurses, and other staff showed inconsistent understanding and implementation of wound assessment and documentation practices. CNAs and other staff described the buttock wounds as looking like “hamburger meat,” oozing, bleeding, with odor and blackened areas, while RNs and LPNs acknowledged that nurses were responsible for wound care, assessments, and documentation. Staff reported that an ADON had previously completed weekly wound assessments and that after the ADON’s departure, expectations for who would perform and document weekly wound measurements were unclear. One LPN who completed a weekly wound assessment stated that measurements were documented on paper and should have been entered into the EMR but was unsure how regularly wounds should be monitored or documented. The DON stated she expected weekly skin and wound assessments with measurements, MD notification for new open areas, and documentation of assessments, but indicated she did not become aware of the wounds opening until around the middle of the month. The Administrator stated an expectation that wounds and skin be assessed, monitored, measured, documented, and that care plans be individualized, which did not occur in this case.
Failure to Maintain Sanitary and Clean Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior environment in resident-use areas, despite written policies requiring routine and cycle cleaning. Surveyors observed multiple instances of unclean conditions throughout several halls and rooms. On Buffalo Blvd. Hall, there was a large dried splatter stain with a white crust on the floor, a large pile of dried leaves accumulated at an exit door, and a resident room with a pillow on the floor amid food crumbs, napkins, tissues, a clear cup, and an empty food box. Between two rooms, an orange medication cart cap and a single blue plastic glove were on the floor. On Memory Lane Hall/Unit, surveyors noted a strong urine odor upon entering. The dining room trash can at the end of the serving counter was overflowing, with trash and napkins on the surrounding floor. In the TV/visiting area, a resident was reclined in a chair next to a wheeled side-table cart heaped with trash, including soda cans, rolled tissues, and wrappers, with food crumbs, tissues, and an elastic hair band on the floor under the recliner. Multiple rooms on this unit had tissue and food crumbs on the floor, large stained discolorations on the floor, popcorn and wadded trash items on the floor, overflowing trashcans, splatter-like stains across the floors, and various discarded items such as straws, wrappers, tissues, Q-tip wrappers, and bottle caps under beds. On a later observation date, one room had a strong urine odor, wadded trash under the bed, and dried, hardened wads of paper splattered onto the floor. On Prairie Lane Hall, a wadded-up piece of paper was observed on the floor outside a room and appeared to remain in the same location several days later. A cognitively intact resident reported usually cleaning the room independently because it took too long for staff to do it, stating that housekeeping staff were good but too few, and that other staff did not help with cleaning. This resident’s room had a strong bowel odor, and the resident pointed out a pile of soiled bedding under the sink counter that had been removed from the bed two days earlier and not picked up, causing embarrassment. Another cognitively intact resident stated that staff would empty trash but took a long time to do so, and that weekdays were better because housekeeping came to help clean rooms. Staff interviews further described ongoing cleanliness issues. A COTA reported noticing the facility in disarray at times and personally cleaning gum wrappers from under a resident’s bed because they had been there so long. A CNA stated the facility was dirty at the start of shifts, that night shift staff were the worst about throwing trash around, and that there was no current housekeeping department head after the prior Maintenance Director left. This CNA also reported that some residents were incontinent and that urine-containing items in trash contributed to odors, and that plumbing issues caused sewer smells, especially after showers. Another CNA reported the facility was filthy on Monday mornings and after weekends, with weekend staff leaving trash in rooms instead of disposing of it. A housekeeper stated it was normal to arrive each day to find trash all over floors, shower rooms with clothes, bedding, and towels scattered, and overflowing trashcans. Another CNA said housekeeping tasks completed depended on who was working, that housekeepers were supposed to clean every room daily and deep clean monthly, and that they always carried trash bags because someone’s room was always dirty. The DON reported there were three or four housekeeping staff, was unsure if housekeeping worked weekends, and stated housekeeping should empty trash, sweep, and wipe surfaces daily, with aides also able to perform these tasks. The Administrator stated an expectation that all staff pick up after any mess they make and that staff try to clean when they notice cleanliness or odor issues.
Failure to Provide Proper Catheter Care and Care Planning for Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate catheter care and related services for a resident with an indwelling urinary catheter, as required by facility policy and the resident’s needs. The resident was cognitively intact, dependent on staff for toileting, and had a diagnosis of neuromuscular dysfunction of the bladder with an indwelling catheter in use. The resident’s care plan addressed monitoring intake and output, catheter tubing kinks, pain or discomfort related to the catheter, and signs and symptoms of urinary tract infections, but did not include any interventions for catheter care. Review of the physician orders for the month showed there were no orders related to catheter care, despite the facility’s written policy requiring catheter care every shift and as needed. During an observed catheter care episode, two CNAs entered the resident’s room, performed hand hygiene, and donned PPE. One CNA removed the resident’s brief while the other cleansed the resident’s inner thighs with a single wet washcloth, folding it over between swipes but not obtaining a new washcloth. The CNA did not remove soiled gloves, perform hand hygiene, or apply new gloves before proceeding. The CNA did not retract the foreskin and cleansed the catheter tubing from the distal end toward the proximal end at the meatus, contrary to the facility policy that required cleansing from the meatus outward. The CNA then provided care to the resident’s backside after bowel incontinence without changing gloves or performing hand hygiene before placing a clean brief under the resident, adjusted the catheter, and hung the catheter bag on the bed. Interviews with the CNA, another CNA, the DON, and the Administrator confirmed that catheter tubing was expected to be cleansed away from the body to prevent infections, which did not occur during the observed care, and that catheter care was not ordered or care-planned for this resident.
Failure to Follow Hand Hygiene and Aseptic Technique During Peri-Care and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, specifically related to hand hygiene, glove use, and prevention of cross-contamination during resident care. For one resident with multiple sclerosis, neuromuscular bladder dysfunction, quadriplegia, and an indwelling catheter, two CNAs entered the room to perform catheter and peri-care. Both CNAs initially performed hand hygiene and donned PPE. One CNA removed the resident’s brief while the other provided catheter care and then cleaned the resident’s backside after bowel incontinence. After providing this care, the CNA obtained a clean brief and placed it under the resident without performing hand hygiene or changing gloves. The same CNA then adjusted the resident’s urinary catheter and hung the catheter bag on the side of the bed, again without performing hand hygiene or changing gloves. The CNA obtained a graduate, drained the catheter bag, emptied the graduate into the toilet, flushed the toilet, touched the resident’s sink, and turned on the water to rinse the graduate, all while wearing the same soiled gloves. Only after these tasks did the CNA remove gloves and perform hand hygiene. The CNA did not sanitize any of the room surfaces that had been touched with soiled gloves. Staff interviews, including with CNAs, the DON, and the Administrator, confirmed that the facility’s expectation was that staff perform hand hygiene and change gloves when moving from dirty to clean surfaces to prevent cross-contamination. A second deficiency occurred during wound care for another resident with cellulitis of the left lower limb, non-pressure chronic ulcers of both lower legs, and open foot lesions. An LPN entered the room to perform wound care on a left leg wound that had an odor, visible brownish-yellow drainage through the gauze wrap, and drainage on a bed pad under the leg. The LPN placed clean dressing supplies on a clean barrier, then applied gloves without hand hygiene, removed the resident’s shoe and sock, used scissors from a pocket to cut off the soiled dressing, and then placed the soiled scissors on the clean barrier next to clean supplies. The LPN removed gloves, did not perform hand hygiene, donned new gloves, and began cleansing the wounds, repeatedly reaching into a bulk bag of gauze and handling clean supplies without changing gloves or performing hand hygiene. The LPN placed the used wound cleanser bottle and clean gauze roll back on the designated clean barrier after touching them with contaminated gloves, briefly acknowledged not remembering all the steps, then removed gloves, performed hand hygiene, donned new gloves, and used the previously contaminated gauze roll to wrap the wound. The LPN then handled the resident’s sock and shoe, placed the leg back on the soiled bed pad, exited the room, removed gloves, used hand sanitizer, and left the contaminated bulk gauze bag, scissors, and wound cleanser on top of the treatment cart. Interviews with CNAs, the DON, and the Administrator confirmed expectations that reusable items used for multiple residents be sanitized before and after use and that soiled hands not be placed into bulk supplies.
Failure to Maintain Effective Pest Control for Fly Infestation in Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to control a significant fly population in resident care areas, despite having a written Pest Control Program policy and contracted pest control services. Pest control inspection documentation showed fly activity on an interior bug light in early December, with no detailed findings documented on a subsequent December visit. On the day of survey, multiple observations revealed numerous flies in and around several residents and their rooms. One cognitively impaired resident was observed in bed with flies buzzing around and crawling on the resident’s hand, legs, body, and bed linens, including five to six flies on the resident’s legs and body during an observation with the DON. Another resident with intact cognition was observed in bed with flies on the forehead and neck, several flies buzzing around the resident, and approximately six flies on the floor beside the bed; later the same day, additional flies were observed around the bed and on the floor in that room. A third cognitively intact resident, seated in a wheelchair in their room, had a fly land on their head and reported that flies were always present in the room and were bothersome, keeping a fly swatter at the end of the bed and keeping the door closed to try to keep flies out. A fourth resident, also in a wheelchair in their room, reported that flies had been bad and had bothered them the previous night while in bed, and a family member present stated they had killed about eight flies during that visit while swatting at flies on the floor. Staff interviews showed that housekeeping expected staff to report flies to a supervisor, and an RN reported that flies had been “everywhere and bad” after a recent warm spell, that they had informed the Administrator and DON about the fly problem, and that flies put residents at risk for skin infections and contamination of food. The DON stated that pest control monitored flies, that staff should report flies to maintenance, that she had not heard recent complaints, and that flies caused infection control issues and a non-homelike environment. The Maintenance Supervisor acknowledged ongoing issues with flies, reliance on bug lights and pest control guidance, and the expectation that staff report flies to him, while the Administrator stated that pest control visited monthly, staff were expected to report flies to maintenance, and staff were expected to kill flies as needed.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to facility management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, a nurse aide (NA C) witnessed another aide (NA D) slap a resident during care after the resident, who has severe cognitive impairment and behavioral symptoms related to dementia, became physically aggressive. Instead of reporting the incident immediately, NA C waited until the following day to inform management, citing discomfort with reporting while still on shift with the involved staff member. The resident involved had a history of vascular dementia, polyneuropathy, and required assistance with personal care, exhibiting frequent behavioral challenges such as yelling, physical aggression, and refusal of care. The care plan for this resident included specific interventions for managing behavioral symptoms, but during the incident, the staff response escalated to physical abuse. The delay in reporting meant that the incident was not brought to the attention of the Administrator until the afternoon of the following day, and the state agency was not notified within the required two-hour window. Interviews with multiple staff members, including CNAs, RNs, the Social Services Director, the DON, and the Administrator, confirmed that facility policy and their training require immediate reporting of abuse allegations to management and notification to the state agency within two hours. Despite this, the actual practice in this case did not align with policy, resulting in a failure to protect the resident and comply with regulatory requirements for timely reporting of abuse.
Failure to Conduct Timely and Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of possible physical abuse involving a resident with severe cognitive impairment and behavioral symptoms related to dementia. The incident occurred when two nurse aides entered the resident's room to provide care, and the resident began hitting one of the aides. In response, the aide allegedly slapped the resident. The incident was not reported immediately; instead, it was reported the following day by the other aide present during the event. Upon review, it was found that the facility's investigation was insufficient. The investigation relied solely on written statements from the two nurse aides involved and did not include interviews with other staff or residents who might have had relevant information. The facility's own policy requires a comprehensive investigation, including interviews with multiple staff and residents, but this was not followed. Additionally, the investigation summary was undated and lacked documentation of immediate protective measures for all residents during the investigation period. The resident involved had a history of severe cognitive impairment, required assistance with activities of daily living, and exhibited behavioral symptoms such as physical aggression toward staff. Despite these vulnerabilities, the facility did not document a full assessment or protective interventions immediately following the allegation. The failure to follow established abuse prevention and investigation protocols resulted in a deficiency related to the facility's response to alleged abuse.
Failure to Document and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate administration and documentation of physician-ordered medications for six residents. Staff did not consistently document medication administration in the Medication Administration Record (MAR) as required by facility policy, resulting in multiple undocumented doses across a range of medications, including insulin, antipsychotics, pain medications, antibiotics, and medications for chronic conditions such as hypertension, COPD, and diabetes. The facility's policy required staff to document all administered medications, note refusals, and provide reasons for any missed doses, but these procedures were not followed. Residents affected had complex medical histories, including diagnoses such as chronic obstructive pulmonary disease, schizophrenia, diabetes, hypertension, depression, and recent acute medical events like peptic ulcer with hemorrhage and perforation. For example, one resident with diabetes and chronic pain did not have documentation for several doses of insulin, pain medication, and other prescribed drugs. Another resident with hypertension, COPD, and a history of fractures had multiple undocumented doses of blood pressure medication, pain medication, and antibiotics. In several cases, there was no documentation in the nurses' progress notes to explain the missed or undocumented doses. Interviews with residents revealed that some experienced increased pain, missed doses, and inconsistent medication administration, which affected their comfort and ability to sleep. Staff interviews confirmed that documentation was sometimes omitted due to being busy, and blank areas on the MAR were not in accordance with policy. The Director of Nursing and Administrator were unaware of the extent of the documentation lapses and missing doses, despite policies requiring staff to notify them if medications were unavailable or not administered.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and appetizing temperatures for three residents who frequently ate in their rooms. Observations and interviews revealed that these residents consistently received meals that were cold or not warm enough, with one resident stating that food was always served cold and another noting that breakfast was usually cold. Although staff offered to reheat or replace meals when complaints were made, residents often declined these offers. A test tray taken from an uninsulated food cart at the end of meal service showed food temperatures below the facility's policy requirements, with all items measuring between 124.3°F and 126°F, which is below the required minimum of 135°F for hot foods. Staff interviews confirmed that complaints about cold food were received, particularly on one hall, and that dietary staff were notified of these issues. The dietary manager and staff demonstrated inconsistent knowledge of the facility's food temperature policy, with some believing that food should be above 120°F or 125°F, rather than the policy-stated 135°F. The administrator stated that staff should not reheat served meals in the microwave but should replace them with fresh meals, though this practice was not consistently followed. The affected residents had diagnoses including diabetes, hyperlipidemia, and GERD, and were cognitively intact, able to report their dissatisfaction with food temperatures.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
Facility staff failed to complete an admission Minimum Data Set (MDS) assessment in a timely manner for one resident. The resident was admitted with multiple diagnoses, including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke. Documentation showed the resident arrived at the facility, but there was no record of an admission MDS being completed. Interviews with the Social Services Director, MDS Coordinator, and Administrator confirmed that the admission MDS should be completed within 14 days of admission, and acknowledged that it was not done for this resident. Additionally, the facility did not provide a policy related to MDS assessments.
Failure to Complete Significant Change MDS After Resident Transfer to Locked Unit
Penalty
Summary
Facility staff failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who was moved to the memory care (locked) unit following multiple documented behavioral incidents. The resident, who had diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes, mild intellectual disabilities, impulse disorder, COPD, and hypertension, was involved in several incidents of theft or loss, such as taking and consuming other residents' food and beverages. After these incidents, the resident was moved to the locked unit, and the guardian was notified. Despite the change in the resident's condition and environment, the most recent MDS assessment on record was a quarterly assessment completed prior to the move. Staff did not complete a significant change MDS within the required timeframe following the behavioral incidents and transfer to the locked unit. Additionally, the resident's care plan was not updated to address the behaviors that led to the move, and the facility did not provide a policy related to MDS assessments. Interviews with facility staff confirmed that a significant change MDS should have been completed and that the care plan had not yet been updated for the resident's behaviors.
Failure to Complete Timely Discharge and Readmission MDS Assessments
Penalty
Summary
The facility failed to complete a discharge with return anticipated Minimum Data Set (MDS) and a readmission MDS within seven days for a resident who was transferred to the hospital and subsequently returned. Review of the resident's records showed that after experiencing chest tightness, tachycardia, and elevated temperature, the resident was sent to the hospital. Documentation confirmed the resident's hospital transfer, but staff did not complete the required discharge MDS for this event. When the resident returned from the hospital several days later, there was also no readmission MDS completed as required. Interviews with facility staff revealed that the Social Services Director was responsible for certain MDS sections, while the MDS Coordinator, who was new to the role, was responsible for completing the discharge MDS. The Administrator acknowledged that a discharge with return anticipated MDS should have been started once the resident was out of the building for 24 hours, and both the Administrator and DON confirmed that the required MDS assessments were not completed in a timely manner. The facility was unable to provide a policy related to MDS assessments during the review.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by facility policy. The policy specifies that a baseline care plan must be created within 48 hours to address the resident's immediate needs, including initial goals, physician and dietary orders, therapy, and social services. Review of the resident's electronic record showed no documentation of a baseline care plan following the resident's admission. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and Director of Nursing, revealed inconsistent understanding of the required timeframe, with some staff stating 72 hours instead of the policy-mandated 48 hours. The resident involved had multiple complex diagnoses, including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke. The resident was admitted to the facility, and nursing staff documented the arrival, but no baseline care plan was completed or documented within the required timeframe. This omission resulted in the resident's immediate care needs not being formally addressed as outlined in the facility's policy.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement accurate, comprehensive care plans for all residents, as evidenced by two specific cases. In the first case, a resident admitted with multiple diagnoses including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke did not have a comprehensive care plan completed within the required timeframe. The resident's electronic medical record showed no documentation of a completed care plan following admission, despite facility policy and staff interviews confirming that such a plan should have been developed within 21 days. In the second case, another resident with diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes mellitus, mild intellectual disabilities, impulse disorder, COPD, and high blood pressure exhibited repeated behavioral incidents involving theft of food and beverages from other residents. These behaviors were documented in multiple incident reports and ultimately led to the resident being moved to a locked memory care unit. However, the resident's care plan was not updated to address these behaviors or the move, contrary to facility policy and staff expectations that care plans should be updated promptly when such behaviors occur or when a resident is transferred to a different unit. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and DON, confirmed that comprehensive care plans should be completed and updated in a timely manner to reflect residents' needs and changes in condition or behavior. The failure to complete and update care plans as required resulted in deficiencies in meeting the comprehensive care planning requirements for these residents.
Failure to Pay Generator Invoices Resulting in Removal of Emergency Power Source
Penalty
Summary
The facility failed to administer its operations in an effective and efficient manner by not paying invoices for a portable generator in a timely fashion. Observation revealed a disconnected natural gas generator on the facility grounds, with no other operational generator present. Review of invoices showed a significant outstanding balance, with amounts overdue for more than 90 days. The generator company had communicated multiple times regarding the overdue payments and warned that the generator would be removed if the balance was not paid. Ultimately, the generator was removed after the facility failed to resolve the outstanding debt. Interviews with facility staff indicated a lack of awareness and communication regarding the unpaid invoices. The Administrator stated that invoices were sent directly to the owners and not to him, and he was unaware of any outstanding balances or issues with the generator. The Director of Fiscal Services reported ongoing negotiations with the generator company over disputed charges, but the generator was removed during these negotiations. The facility did not provide a policy regarding the timeliness of payments to service providers.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months completed a state-approved CNA training program, competency evaluation, and certification test within the required timeframe. Specifically, two nurse aides continued to provide direct care to residents without documentation of CNA certification beyond the 120-day limit. Review of personnel files confirmed the absence of certification for both aides, and interviews with the DON and Administrator revealed that oversight and follow-through on certification requirements were lacking. Additionally, the facility did not provide a policy regarding nurse aide training classes.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
Staff failed to provide appropriate incontinent care for a resident with Alzheimer's disease, chronic kidney disease, and benign prostatic hyperplasia, who was dependent on staff for activities of daily living. The resident's care plan required frequent checks, assistance with toileting, and peri-care after each incontinent episode. Despite these directives, the resident was observed seated in a Broda chair near the nurses' station for an extended period, during which time a visible puddle of urine formed under the chair and the resident's clothing and chair became saturated with urine. Multiple staff members, including a registered nurse, certified medication tech, and nurse aides, passed by or interacted with the resident but did not check or change the resident or address the incontinence, even after the presence of urine was apparent. The resident remained in the same location for over two hours without being checked or changed, despite the facility's policy and staff statements that residents should be checked every two hours and as needed. It was only after the surveyor intervened and requested the resident be checked that staff provided incontinent care, changed the resident's clothing, and cleaned the chair. Interviews with staff revealed uncertainty about when the resident was last checked or changed, with some staff citing a busy workload and others indicating that the resident had been in the Broda chair since before their shift began. Staff acknowledged that the resident should have been checked and changed sooner, and that the presence of a puddle should have prompted immediate action. The deficiency was due to staff inaction and failure to follow the care plan and facility policy regarding incontinent care.
Ineffective Resource Management
Penalty
Summary
The facility was cited for not administering its resources effectively and efficiently, as noted in event ID NQRP12. The deficiency was identified during a survey with an exit date of January 14, 2025. The report does not provide specific details about the actions or inactions that led to this citation, nor does it mention any particular residents or staff involved. The citation is linked to the facility's overall management and resource utilization practices.
Inadequate RN and DON Staffing Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure consistent and sufficient Registered Nurse (RN) and Director of Nursing (DON) hours, which impacted the DON's ability to fulfill her duties. The DON frequently had to work as a charge nurse or certified nurse aide, which left her behind on essential DON responsibilities such as reviewing physician orders, tracking labs, hiring and terminating staff, and monitoring the infection prevention and antibiotic stewardship programs. The DON reported working multiple shifts on the floor, including every weekend in September, which contributed to the backlog in her administrative duties. Additionally, the facility did not implement an effective antibiotic stewardship program, as there were no measures in place to track residents on antibiotics for various infections. This lack of tracking was confirmed by the DON during interviews. Furthermore, the facility failed to ensure residents were free of significant medication errors, as staff did not administer warfarin sodium per physician's orders. There were also instances where ordered medications were unavailable on-site, preventing administration to residents. The DON acknowledged reviewing a computer dashboard daily for missed or unavailable medications, but these issues persisted.
Deficiency in Employing Qualified Dietary Manager
Penalty
Summary
The facility staff failed to employ a qualified dietary manager for the food and nutrition services department, as required by regulatory guidelines. The dietary manager, who started the position in March 2024, did not possess the necessary qualifications such as being a certified dietary manager (CDM), a certified food services manager, or having an associate's degree or higher in food service management or hospitality. The dietary manager had previous experience as a nutritional assistant and completed a certificate of proper temperature safety through the health department, but these credentials did not meet the requirements for the Director of Food and Nutrition Services (DFNS) in a long-term care setting. During an interview, the dietary manager confirmed the lack of required certifications and training. Additionally, the facility administrator admitted to being unaware of the necessary qualifications for the dietary manager position and indicated plans to send the manager to the required classes. The facility did not provide documentation of certification, training, or experience that met the regulatory requirements for the DFNS, resulting in a deficiency in employing appropriately qualified staff for the food and nutrition services department.
Infection Control Deficiencies in Legionella Prevention and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, particularly in preventing the growth of Legionella bacteria in the water supply. The facility did not conduct a Legionella risk assessment, lacked a diagram of the water system, and did not monitor water temperature or pH levels to prevent Legionella growth. The Maintenance Director was unaware of the necessary water temperature and pH levels and did not know the location of the facility's water system map. The Administrator confirmed that only resident room sinks and toilets were flushed, with no other preventive measures taken. Additionally, the facility did not have a policy or procedure for hand hygiene, leading to multiple instances of non-compliance with hand hygiene standards during medication passes. The Director of Nursing (DON) and Certified Medication Technicians (CMTs) were observed not performing hand hygiene before and after resident contact, after glove removal, and between medication passes. The DON was seen handling medical equipment and administering medications without washing hands, and CMTs were observed preparing and administering medications without performing hand hygiene. Interviews with staff, including CNAs, LPNs, and RNs, revealed that they were aware of the importance of hand hygiene but did not consistently practice it. The DON and Administrator acknowledged the expectation for staff to perform hand hygiene, yet observations showed a lack of adherence to these standards, contributing to the facility's failure to maintain an effective infection control program.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a current and ongoing antibiotic log for residents with active infections. The facility's policy, dated December 2016, outlined that antibiotics should be prescribed and administered under the guidance of the Antibiotic Stewardship Program, with specific requirements for prescribers to provide detailed information about the antibiotic orders. However, the facility only provided a computer printout of residents prescribed antibiotics for September, with no additional documentation of antibiotic tracking measures. Interviews with the Director of Nursing (DON) revealed that while a monthly report of antibiotic usage is obtained and reviewed with the physician, there were no residents currently on antibiotics, and no other tracking measures or notes from the monthly physician meeting were documented. The DON also mentioned that outcome surveillance related to antibiotic use was not tracked, and although a new urinalysis is obtained upon completion of antibiotics, the results are not logged. The Administrator expected staff to follow guidelines for prescribed antibiotics, but the lack of documentation and tracking measures indicates a deficiency in the facility's antibiotic stewardship program.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and documentation for two residents, leading to deficiencies in wound management. For Resident #152, the staff did not consistently assess and document the resident's pressure ulcers on the right and left buttocks. Despite the presence of stage 2 pressure ulcers, the facility's records frequently omitted documentation of the right buttock ulcer, and there were no documented treatment orders in the system for the wounds. The resident was admitted with pressure ulcers, and the facility's policy required weekly wound assessments and documentation, which were not consistently followed. Resident #6 also experienced inadequate wound care documentation. The resident had a history of type two diabetes, peripheral vascular disease, and heart failure, and was at risk for pressure ulcers. The resident's care plan included orders for wound care, but the documentation was incomplete, with missing records for the left buttock wound and inconsistent weekly wound observations. The resident's wounds were not properly documented in the facility's system, and there was a lack of follow-through on treatment orders. Interviews with staff, including the DON and RN, revealed that the former wound nurse did not enter treatment orders into the computer system, leading to a lack of documented care. The facility's failure to adhere to its wound care policy and ensure proper documentation and treatment of pressure ulcers resulted in deficiencies in the care provided to these residents.
Deficiencies in Oxygen Equipment Management for Residents
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for two residents, resulting in deficiencies related to the management of oxygen equipment. Resident #46, who has diagnoses including chronic obstructive pulmonary disease (COPD), heart disease, and chronic kidney disease, was observed with an oxygen concentrator and portable oxygen tank with undated or illegibly dated nasal cannulas and tubing. Despite physician orders to change the oxygen humidifier and tubing weekly, observations revealed that the equipment was not changed as scheduled, with dates on the equipment indicating it had not been updated since 09/16/24. Similarly, Resident #36, diagnosed with COPD and interstitial pulmonary disease, was also found with undated nasal cannulas and tubing that had not been changed since 09/16/24, contrary to the weekly change orders. Additionally, the resident's care plan did not include documentation of oxygen use, which is a critical component of their care. The September 2024 Medication Administration Record (MAR) lacked documentation for changing the humidifier and oxygen orders, further indicating a lapse in following prescribed care protocols. Interviews with facility staff, including Certified Medication Technicians, Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides, revealed inconsistencies and confusion regarding responsibilities for changing oxygen equipment. Staff members provided conflicting information about who was responsible for changing the tubing and when it should be done. The Director of Nursing confirmed that oxygen tubing should be changed weekly and that both nurses and aides are responsible for this task, yet the deficiency persisted, indicating a lack of adherence to established procedures and communication breakdowns among staff.
Inadequate Pain Management Due to Medication Unavailability and Documentation Failures
Penalty
Summary
The facility failed to provide effective pain management for residents, as evidenced by the failure to administer pain medications as ordered and the lack of documentation for pain medication orders. Resident #252, who was admitted with multiple fractures and high blood pressure, did not receive the prescribed morphine sulfate and Percocet due to delays in pharmacy delivery. Despite the resident's complaints of pain and requests for medication, staff only offered Tylenol, which was ineffective. The resident's pain levels were consistently documented as moderate, yet the ordered medications were not administered, and staff failed to provide alternative pain management solutions. Resident #36, diagnosed with COPD, prostate cancer, and interstitial pulmonary disease, also experienced inadequate pain management. The resident's prescribed Tylenol and oxycodone were not administered on multiple occasions due to unavailability. Upon returning from a leave of absence, the resident requested pain medication, but the facility did not have the prescribed oxycodone in stock. Although a substitute order for hydrocodone was obtained, it was not documented in the physician orders or the MAR, leading to further delays in pain relief. The resident reported severe pain levels, and staff interviews revealed ongoing issues with medication availability and documentation. Interviews with staff, including RNs, LPNs, and the DON, highlighted systemic issues with medication procurement and documentation. The facility struggled with timely medication delivery from the pharmacy, and there were instances where substitute medications were not properly documented. Staff were aware of the residents' pain but were unable to provide the necessary medications due to these logistical challenges. The facility's failure to adhere to its pain management policy resulted in prolonged periods of unrelieved pain for the residents involved.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12.82% error rate with five medication errors out of 39 opportunities. These errors affected three residents. The errors included administering the wrong form of medication, incorrect dosages, and improper administration techniques. For instance, a Certified Medication Technician (CMT) administered a guaifenesin tablet instead of the prescribed liquid form to a resident with diabetes mellitus and congestive heart failure. Another resident, who was cognitively intact and diagnosed with throat cancer, lupus, and diabetes mellitus, received an incorrect dosage of olanzapine and the wrong form of ondansetron. The CMT administered a 10 mg tablet of olanzapine instead of the prescribed 5 mg and an orally dissolving tablet of ondansetron instead of the regular tablet form. These actions were contrary to the physician's orders and the facility's medication administration policy. Additionally, a resident with a feeding tube, diagnosed with nontraumatic intracerebral hemorrhage and respiratory failure, received medications improperly combined and administered through the g-tube. The Director of Nursing (DON) crushed and mixed hydralazine and tramadol tablets without a physician's order to combine them, contrary to the facility's policy and best practices for administering medications via enteral feeding tubes. This improper technique was observed during a medication administration process, highlighting a significant deviation from the prescribed method of administering and flushing medications separately.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to standards of practice, specifically regarding the storage of controlled substances and the security of medication carts. Observations revealed that controlled substances for two residents were not stored under two locks as required. Resident #1, who had diagnoses including human immunodeficiency virus and acute kidney failure, had a prescription for dronabinol capsules stored in an unlocked refrigerator. Similarly, Resident #39, with conditions such as benign intracranial hypertension and cancer, also had dronabinol capsules stored in the same unsecured manner. Additionally, medication carts were observed to be left unlocked and unattended on multiple occasions. One instance involved a nurse medication cart outside the Director of Nursing's office, which contained insulin pens and narcotics, being left unlocked while residents were nearby. Another observation noted the Director of Nursing leaving a cart unlocked near the nurses' station, with several residents in the vicinity. Interviews with staff, including Certified Medication Technicians and Registered Nurses, confirmed that medication carts and storage areas should be locked when not in use. However, the observations indicated a failure to adhere to these protocols, as controlled medications were found unsecured in the refrigerator, and medication carts were left unattended and unlocked. The Director of Nursing and Administrator acknowledged these lapses, emphasizing the expectation for medications to be stored securely and under double lock for narcotics.
Failure to Provide Accessible Hydration for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's hydration needs, as observed during a survey. The resident, who had diagnoses including chronic kidney disease, COPD, and heart failure, was found without accessible water on multiple occasions. The resident's care plan required nectar/mildly thick consistency liquids to be provided in a two-handled cup with a lid and spout. Despite this, observations showed that water was either out of reach or not present in the resident's room, and the resident was observed to be visibly thirsty with a dry mouth. Interviews with facility staff, including a CNA, RN, and the Director of Nursing, revealed that there was a misunderstanding about the resident's ability to have water in the room due to the need for thickened liquids. Staff were responsible for ensuring water was accessible during rounds every two hours, but this was not consistently done. The CNA mentioned that they were initially told the resident couldn't have water due to choking risks, but this was later clarified. Despite these instructions, the resident did not have water accessible, leading to the deficiency noted by the surveyors.
Failure to Complete PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to administer the required Preadmission Screening and Resident Review (PASARR) Level 1 screening for a resident with mental disorders prior to their admission. The resident, who was admitted with diagnoses including major depressive disorder, bipolar disorder, and psychosis, did not have a PASARR completed as required. The facility's policy mandates coordination with the Medicaid PASARR program to determine the nursing and medical needs of individuals with mental disorders, and potential residents with such conditions should only be admitted if the state mental health agency has determined the necessity of the level of service provided by the facility. The resident's records indicated cognitive intactness but an inability to complete a mental status interview, along with symptoms such as delusions and the use of antidepressant, antianxiety, and antipsychotic medications. The care plan noted confusion, disorganized thinking, and socially inappropriate behavior. Despite these indicators, a PASARR was not completed, as confirmed by an email from the Central Office Medical Review Unit. Interviews with the Social Services Designee and the Administrator revealed that the responsibility for completing the PASARR fell on the SSD, who admitted to completing it only if the hospital had not done so prior to admission.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident #15, by not ensuring the availability of prescribed medication, escitalopram oxalate, on multiple occasions. The resident, who had diagnoses including schizophrenia and major depressive disorder, required this medication as part of their treatment plan. Despite having a documented order for the medication, it was not administered on several dates in August and September 2024 due to unavailability. The facility's policies required timely reordering of medications and follow-up with the pharmacy to prevent lapses in administration. However, the documentation showed that the medication was not available on multiple dates, and staff did not consistently follow up with the pharmacy or utilize the emergency kit as per the facility's procedures. Interviews with staff, including Certified Medication Technicians (CMTs) and the Director of Nursing (DON), revealed a lack of communication and follow-up regarding the medication's unavailability. The DON acknowledged that the missed doses coincided with a period when physician orders were being redone for the pharmacy. Despite the facility's system for entering and faxing orders to the pharmacy, the medication was not received in a timely manner. The DON and other staff members were not consistently aware of the medication's unavailability, and the facility's dashboard, which tracks missed or unavailable medications, was not reviewed daily as required. This resulted in multiple missed doses of the resident's essential medication, highlighting a deficiency in the facility's pharmaceutical services.
Failure to Administer Warfarin as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff did not administer warfarin sodium as per the physician's order. The resident, who had a diagnosis of thrombophilia and an abnormal coagulation profile, was supposed to receive warfarin sodium, a blood thinner, to prevent blood clots. The medication was on hold from September 6th to September 11th, but after the hold ended, the resident missed three doses on September 11th, 12th, and 13th because the medication was reportedly unavailable. Certified Medication Technician (CMT) B documented that the warfarin sodium was not available on these dates and did not notify the Director of Nursing (DON) or the physician about the missed doses. Interviews revealed that CMT B was unaware that the medication was in a pill bottle until informed by the resident's responsible party. The facility's policy required staff to report any discrepancies in medication administration immediately to the DON and notify the physician and family, which was not done in this case. The DON and other staff members confirmed that the medication should have been available, possibly in the emergency kit, and that the resident should not have gone without warfarin for more than a couple of days due to the risk of blood clots. The facility's computer system was supposed to alert staff to medications not administered, and the DON was expected to review this daily. However, the missed doses were not reported or addressed in a timely manner, leading to a significant medication error.
Incomplete Documentation for Resident Transfers
Penalty
Summary
The facility failed to maintain complete medical records for two residents who were transferred to the hospital and later returned. For Resident #41, the nursing progress notes did not document the reason for the transfer, the time of transfer, or notification to the physician. Additionally, there was no record of the time or date of the resident's return from the hospital or physician notification of the return. The resident had a history of cerebral infarction, atrial fibrillation, and a fracture of the right femur, and was admitted to the ICU with atrial fibrillation, a urinary tract infection, and sepsis. For Resident #46, the nursing progress notes failed to document the notification of the physician regarding the transfer to the hospital. The resident was admitted to the hospital with an intestinal infection due to Clostridiodes difficile and returned to the facility without documentation of the return or physician notification. The resident had chronic obstructive pulmonary disease, heart disease, and chronic kidney disease, and was sent to the emergency room due to diarrhea and vomiting, which posed a risk of dehydration and acute kidney injury. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that there were expectations for obtaining physician orders for transfers and documenting all relevant details in the resident's medical records. However, these procedures were not followed, leading to incomplete documentation for the residents involved.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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