Camdenton Windsor Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Camdenton, Missouri.
- Location
- 2042 N Business Route 5, Camdenton, Missouri 65020
- CMS Provider Number
- 265091
- Inspections on file
- 19
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Camdenton Windsor Estates during CMS and state inspections, most recent first.
Facility staff discharged a resident to a hospital and then refused to allow the resident to return, without having an emergency discharge policy in place. Staff documented an immediate discharge notice stating the facility could no longer meet the resident’s needs and listed the hospital as the discharge destination. The administrator stated the resident would not be accepted back due to safety concerns for other residents and acknowledged that the hospital was not an acceptable discharge location. A care plan coordinator notified the hospital social worker by email that the facility would not readmit the resident, resulting in an inappropriate emergency discharge notice and failure to ensure the transfer/discharge met the resident’s needs and preferences.
Staff did not review or revise care plans for three residents after they experienced falls, despite facility policy requiring updates following changes in condition. The MDS Coordinator, responsible for care plan updates, had not added new interventions after the falls, and interviews confirmed that care plans were not promptly revised to reflect these incidents.
Staff did not complete or document required neurological checks for two residents with severe cognitive impairment following unwitnessed falls, as mandated by facility policy. Despite clear procedures for post-fall neurological assessments, records and interviews confirmed the absence of documentation and completion of these checks.
A facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment to the DHSS within the required two-hour timeframe. A CNA reported that an RN hit the resident and threw a sheet over their head, but the report was made to the administrator later in the afternoon. The CNA was unaware of the immediate reporting requirement and was educated on their responsibility to notify management promptly.
The facility did not document the administration of the pneumococcal vaccine for six out of eight sampled residents, despite having signed consents. This lapse occurred even though CDC guidelines recommend specific vaccination protocols based on age and prior vaccine history. One resident was diagnosed with pneumonia following chest congestion, underscoring the potential risks. The DON acknowledged delays in vaccine delivery due to conflicting information from the pharmacy and an allergic resident causing a specific vaccine order to be canceled. Staff emphasized the importance of documentation and obtaining consents upon admission, while the MD highlighted the need for timely vaccine administration to prevent respiratory infections.
Facility staff failed to ensure pureed food items were reheated to proper temperatures and did not follow puree recipes. Hot foods were not held at 140°F or greater during meal service, and hot food on room trays for three residents was not maintained at 120°F at the time of delivery. Staff were unaware of the appropriate food temperatures and did not take corrective actions when food was served below the required temperature.
The facility staff failed to implement complete water management policies to prevent Legionnaire's Disease and did not consistently follow proper hand hygiene protocols, leading to potential infection risks for residents.
Facility staff failed to maintain a clean and homelike environment by not properly cleaning resident rooms and common areas. Observations showed debris and dirty floors, and the Housekeeping Supervisor used visibly dirty mop water to clean various areas, which could spread germs and cause infections. Staff interviews confirmed that mop water should be changed every three rooms or when visibly dirty.
Facility staff failed to accurately document MDS assessments for several residents, including the use of BiPAP/CPAP machines, rejection of care behaviors, and anticoagulant medications. Interviews revealed a lack of awareness and understanding regarding proper MDS coding and the classification of medications.
Facility staff failed to develop and implement comprehensive care plans for four residents, leading to undocumented oxygen use, missing podus boot applications, unaddressed weight loss risk, and lack of BiPAP and hospice care documentation. Staff interviews and observations confirmed these deficiencies.
Facility staff failed to ensure residents who were unable to complete their own ADLs received necessary care and services to maintain good personal hygiene. Four residents were observed with unkempt hair and facial hair despite care plans indicating preferences for being clean-shaven. Staff interviews confirmed that residents were expected to receive showers twice a week, but documentation and observations indicated this standard was not consistently met.
Facility staff failed to lock medication and treatment carts and did not store medications and chemicals safely. Observations showed unattended carts with accessible medications and chemicals, and interviews confirmed that staff were aware of the policies but did not adhere to them. The facility lacked a specific chemical storage policy, and issues with cart locks had been reported but not addressed.
Facility staff failed to store oxygen/nebulizer masks and tubing properly, leading to potential contamination for six residents. Additionally, two residents lacked orders for oxygen therapy. Staff interviews revealed a lack of knowledge and adherence to proper procedures, highlighting systemic issues in the facility's handling of respiratory care equipment.
Facility staff failed to accurately count controlled medications for two residents and did not remove expired medications and supplies. An LPN admitted to taking shortcuts, and expired items were found in the medication storage room. The DON and administrator confirmed that proper procedures were not followed.
The facility failed to provide an appropriate 30-day discharge notice and did not allow a resident to return after hospital discharge. The resident's medical record lacked the required discharge notice, and the facility decided not to readmit the resident due to additional information about the resident's history and behaviors.
Improper Emergency Discharge and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to ensure an appropriate and safe transfer/discharge for a resident when they discharged the resident to a hospital and refused to allow the resident to return. Record review showed the resident had been admitted to the facility in early February and was discharged to the hospital on 02/23/26. On 3/3/26 at 11:52 A.M., staff documented in the progress notes that they spoke with the resident’s guardian regarding a notice of immediate discharge because the facility could no longer meet the resident’s needs, and an Immediate Discharge Notice dated 3/3/26 indicated the resident would discharge to the hospital. The facility did not have a policy for emergency discharge, and the administrator stated on 3/3/26 at 10:09 A.M. that the resident would not be accepted back due to safety concerns for other residents and acknowledged awareness that the hospital was not an acceptable discharge location. The care plan coordinator reported emailing the hospital social worker to inform them that the facility would not accept the resident back, effectively using the hospital as the resident’s discharge destination without appropriate notice or planning to meet the resident’s needs and preferences for a safe transfer/discharge. These actions and omissions, including the lack of an emergency discharge policy, the issuance of an immediate discharge notice listing the hospital as the discharge location, and the administrator’s refusal to readmit the resident, led to the deficiency related to failure to provide an appropriate emergency discharge notice and to ensure the transfer/discharge met the resident’s needs and preferences.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for three residents who experienced falls. According to the facility's policy, care plans are to be updated with measurable goals and interventions as changes occur in a resident's condition, including after falls. For each of the three residents, documentation showed that after they sustained falls—some resulting in injury and others not—there were no new interventions added to their care plans. The MDS Coordinator, responsible for updating care plans, stated that due to assisting with resident care, they had not had the opportunity to update the care plans following these incidents. The administrator and DON both indicated that they would expect new interventions to be added after each fall, depending on the circumstances. Interviews with staff confirmed that the care plan is intended to guide care and should be updated after changes such as falls. In one case, the MDS Coordinator was unaware of a resident's fall, and in another, staff provided education to the resident but did not document a new intervention in the care plan. The facility census at the time was 49, and the sampled residents had varying levels of cognitive impairment and histories of both injury and non-injury falls. The lack of timely care plan updates following these events constituted the deficiency.
Failure to Complete and Document Neurological Checks After Unwitnessed Falls
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Summary
Facility staff failed to complete and document neurological checks for two residents who experienced unwitnessed falls, as required by facility policy. The policy mandates neurological assessments for seventy-two hours following an unwitnessed fall or head injury, with specific intervals for checks and documentation in the medical record. For both residents, who had severe cognitive impairment and a history of falls, there was no documentation in event reports or progress notes indicating that neurological checks were performed after their unwitnessed falls. Interviews with staff, including an LPN, the MDS Coordinator, the administrator, and the DON, confirmed that neurological checks should have been completed and documented for residents after unwitnessed falls. However, staff were unaware of the missing documentation for these two residents, and the DON only identified and addressed a separate missed assessment. The required neurological assessments for these two incidents were not completed or documented as per facility policy.
Failure to Timely Report Alleged Abuse
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Summary
The facility staff failed to report an allegation of physical abuse involving a resident with severe cognitive impairment to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The incident involved a Certified Nurse Aide (CNA) who reported that a Registered Nurse (RN) hit the resident and threw a sheet over their head. The CNA reported the incident to the administrator later in the afternoon, which was beyond the mandated reporting period. The facility's investigation policy requires all allegations of abuse to be reported to the State Survey Agency and, if applicable, law enforcement within two hours. Interviews revealed that the CNA was unaware of the immediate reporting requirement and only reported the incident when they first had contact with the administrator. The administrator confirmed that the CNA did not know to report allegations of abuse immediately and stated that the CNA was educated on their responsibility to notify management as soon as abuse was witnessed. The RN confirmed that staff are directed to notify upper management and the State agency within two hours of reported or observed abuse.
Pneumococcal Vaccine Documentation Lapses Identified
Penalty
Summary
The facility failed to document the administration of the pneumococcal vaccine for six out of eight sampled residents, despite CDC guidelines recommending specific vaccination protocols based on age and prior vaccine history. Medical records for Residents #8, #14, #21, #25, #33, and #38 did not contain documentation of staff offering or administering the pneumococcal vaccine, even though signed consents were present for vaccine administration. Notably, Resident #25 was diagnosed with pneumonia after being diagnosed with chest congestion, highlighting the potential consequences of missed vaccinations in this population. During interviews, the Director of Nursing (DON) acknowledged the delay in vaccine delivery, with conflicting information on the expected arrival dates provided by the pharmacy. The DON also mentioned an allergic resident causing a specific vaccine order to be canceled. The facility's staff, including the DON, Licensed Practical Nurse (LPN), Business Office Manager (BOM), and Administrator, emphasized the importance of documentation and the responsibility of obtaining consents for vaccinations upon admission. The Medical Director (MD) stressed the expectation for timely vaccine administration for long-term care residents to prevent potential outcomes like pneumonia or upper respiratory infections.
Failure to Maintain Proper Food Temperatures and Follow Puree Recipes
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Summary
Facility staff failed to ensure pureed food items were reheated to proper temperatures and did not follow puree recipes. Observations showed that hot foods were not held at 140 degrees Fahrenheit or greater during meal service. Additionally, hot food on room trays for three residents was not maintained at 120 degrees Fahrenheit at the time of delivery. Staff, including nurse aides and certified nursing assistants, were unaware of the appropriate food temperatures and did not take corrective actions when food was served below the required temperature. The facility's policy indicated that food should be at least 120 degrees Fahrenheit, but this was not consistently followed. Resident #27, who had moderately impaired cognition and required set-up assistance for eating, received food that was below the required temperature. The resident's stuffing, turkey, and green beans were all served at temperatures below 120 degrees Fahrenheit, and the nurse aide did not offer to reheat the food or provide a new tray. Resident #25, who was cognitively intact and also required set-up assistance, received ham that was below the required temperature. The nurse aide acknowledged the food was below 120 degrees Fahrenheit but did not take corrective action. Resident #105, who was cognitively intact and required set-up assistance, received a dinner tray with food below the required temperature, and the nurse aide did not reheat the food. The facility's dietary staff also failed to follow proper procedures for reheating and holding pureed food items. Observations showed that pureed meatloaf, scalloped potatoes, and bread were not reheated to the required 165 degrees Fahrenheit and were held at temperatures below 140 degrees Fahrenheit. The cook did not check the temperatures of the food before placing them on the steam table and did not follow the puree recipes. The dietary manager confirmed that the cook was responsible for ensuring proper food temperatures and consistency but acknowledged that the food items were not prepared correctly. The administrator stated that food should be 140 degrees Fahrenheit when served to residents, but this standard was not met.
Inadequate Water Management and Hand Hygiene Practices
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Summary
The facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water system to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease. The maintenance director was unaware of whether the public water supply was treated or if the facility had any disinfectants as part of the water system. Additionally, the maintenance director did not check the water for disinfectant or chlorine levels, and the water management program did not include policies or procedures related to control measures or disinfectant levels. Facility staff also failed to perform proper hand hygiene for two residents. One nurse assistant performed catheter care on a resident but did not follow proper hand hygiene protocols, such as washing hands after touching potentially contaminated surfaces and before providing care. Similarly, a licensed practical nurse performed wound care on a resident but did not follow proper hand hygiene procedures, including turning off the faucet with their elbow instead of using a paper towel. Another certified nurse assistant failed to perform proper hand hygiene while providing perineal care to a resident. The CNA did not wash their hands between glove changes and touched various surfaces and the resident with soiled gloves. Interviews with staff, including the Director of Nursing and the Quality Assurance nurse, revealed that staff were aware of the proper hand hygiene protocols but did not consistently follow them, leading to potential risks of infection and cross-contamination.
Failure to Maintain Clean and Homelike Environment
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Summary
Facility staff failed to provide a clean, homelike, and comfortable environment by not maintaining resident rooms and common areas. Observations revealed debris on the floors outside multiple rooms and dirty floors in resident-occupied rooms. Additionally, there were multiple stains and black marks on the walls and floors of some resident rooms. The Housekeeping Supervisor acknowledged that some marks on the walls needed painting, which was a task for the maintenance team. Further observations showed that the Housekeeping Supervisor used dark brown, visibly dirty mop water to clean various areas, including the MDS office, staff bathroom, hallway, clean utility room, and resident-occupied rooms. Interviews with housekeeping staff, a CNA, an LPN, the Housekeeping Supervisor, the DON, and the Corporate QA nurse confirmed that mop water should be changed every three rooms or when visibly dirty. The use of dirty mop water was recognized as a practice that could spread germs and cause infections. The Housekeeping Supervisor admitted to being unaware of using dirty water for cleaning.
Inaccurate MDS Documentation
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Summary
Facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment for several residents. Specifically, staff did not accurately code for the use of Bi-level Positive Airway Pressure (BiPAP) or Continuous Positive Airway Pressure (CPAP) machines for three residents. For instance, one resident's care plan indicated the use of a BiPAP machine at night, but this was not reflected in the MDS assessment. Similarly, another resident's MDS assessment did not document the use of a CPAP machine, despite observations and care plans indicating its use at night. Additionally, the facility staff did not accurately document a resident's rejection of care behaviors in the MDS assessment, even though multiple nurse's notes and interviews confirmed the resident's refusal of showers and other care activities. The MDS assessments also failed to accurately code the use of anticoagulant medications for two residents. The staff incorrectly identified Clopidogrel as an anticoagulant, which led to inaccurate MDS coding. Interviews with the Director of Nursing (DON), MDS Coordinator, and other staff revealed a lack of awareness and understanding regarding the correct classification of Clopidogrel and the importance of accurate MDS documentation. The facility did not have a specific policy for MDS assessments and relied on the Resident Assessment Instrument (RAI) manual for guidance. The MDS Coordinator, who is responsible for completing the MDS assessments and care plans, admitted to not being aware that Clopidogrel is an antiplatelet medication and not an anticoagulant. The DON and other staff members also confirmed that the MDS assessments should accurately reflect the use of oxygen, BiPAP, CPAP, and anticoagulant medications.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan for four residents out of 14 sampled residents. Resident #6, who was assessed as cognitively intact and diagnosed with sleep apnea, did not have an order for oxygen documented in the care plan despite using oxygen at night. The Director of Nursing and Licensed Practical Nurse confirmed the absence of a current oxygen order and the resident's refusal to use CPAP, preferring oxygen instead. This discrepancy was observed during multiple interviews and record reviews, highlighting a lack of proper documentation and care planning for the resident's oxygen use. Resident #14, assessed as cognitively intact and dependent on staff for all Activities of Daily Living (ADLs), was at risk for pressure ulcers. Despite having an order for a podus boot to be worn at all times, the care plan did not document this requirement. Observations on multiple occasions showed the resident without the podus boot, and staff failed to apply it even after providing care. Interviews with various staff members, including CNAs and LPNs, confirmed the expectation that the podus boot should be documented and applied as per the care plan, which was not adhered to. Resident #21, assessed as cognitively intact and requiring setup assistance for eating, experienced significant weight loss over several months. The care plan did not address the resident's risk for weight loss or include any interventions. Interviews with the resident and staff revealed that the resident often ate in their room, but the care plan lacked necessary documentation to manage the weight loss risk. Similarly, Resident #25, with diagnoses including obesity, sleep apnea, and acute bronchospasm, had an order for BiPAP at bedtime, which was not documented in the care plan. Observations and staff interviews confirmed the presence of the BiPAP machine and the need for its inclusion in the care plan, which was not done. Lastly, Resident #33, with severe cognitive impairment and on hospice care, did not have hospice care directions documented in the care plan despite being admitted to hospice services. Interviews with staff consistently indicated that the care plans should be individualized and updated with all relevant information, which was not the case for these residents.
Failure to Provide Necessary ADL Assistance
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Summary
Facility staff failed to ensure residents who were unable to complete their own activities of daily living (ADLs) received the necessary care and services to maintain good personal hygiene. Specifically, staff did not provide hair care and assist residents with facial hair for four residents out of fourteen sampled. The facility's policies did not adequately address the frequency and procedures for hair care, facial hair care, and nail care, contributing to the deficiency observed by surveyors. Resident #14, who was cognitively intact but dependent on staff for all ADLs, was observed multiple times with long chin hairs despite expressing a preference to be clean-shaven. The resident's care plan did not include directions for facial hair preference, and shower documentation repeatedly lacked records of shaving being completed. Similarly, Resident #24, who was severely cognitively impaired and dependent on staff for all ADLs, was observed with facial hair on several occasions, despite a care plan indicating a preference for being clean-shaven. Resident #33, also severely cognitively impaired and requiring maximum assistance for personal hygiene, was observed with unkempt hair and facial hair approximately half an inch long on multiple occasions. The resident's care plan indicated a preference for being clean-shaven, but shower documentation did not reflect that shaving was completed. Resident #50, who was severely cognitively impaired and dependent for all ADLs, was observed with greasy, disheveled hair and unshaved facial hair on several occasions, despite a care plan that indicated a preference for being clean-shaven or having facial hair as needed. Interviews with staff confirmed that residents were expected to receive showers twice a week, but documentation and observations indicated that this standard was not consistently met.
Failure to Lock Medication and Housekeeping Carts
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Summary
Facility staff failed to lock medication and treatment carts and did not store medications and chemicals safely. Observations showed a Certified Medication Technician (CMT) left a medication cart unattended with pills on top, and a treatment cart was found unlocked and unattended at the nurse's station. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that medication and treatment carts should be locked when not attended, and medications should not be left on top of the carts. The CMT admitted to leaving the medication on top of the cart due to being busy with other tasks, acknowledging the potential danger to residents who wander and get into things. Housekeeping carts were also found unlocked and unattended with bottles of toilet bowl cleaner on them. Multiple observations showed housekeeping carts left in various locations, including near resident rooms and the dining room, with chemicals accessible to residents. Interviews with housekeeping staff, the Housekeeping Supervisor, and the Maintenance Director revealed that the carts' locks were not functioning properly, and the issue had been reported but not yet addressed. Staff acknowledged that chemicals should be locked up to prevent residents from accessing them and potentially getting harmed. The facility's policy on the storage of medication directed that all medications must be stored in locked cabinets, rooms, or carts, and that poisonous substances and hazardous compounds must be kept in locked containers away from residents. However, the facility did not have a specific chemical storage policy. The Administrator and DON reiterated that all medication and treatment carts, as well as housekeeping carts with chemicals, should be locked when not attended to ensure resident safety.
Improper Storage and Lack of Orders for Respiratory Care Equipment
Penalty
Summary
Facility staff failed to store oxygen/nebulizer masks and tubing in a manner to prevent infection-causing contaminants for six residents. Observations showed that oxygen tubing was not dated, and BiPAP and CPAP machines and masks were not stored in bags. Additionally, nebulizer masks and tubing were found not dated and not stored in bags, leading to potential contamination. These deficiencies were observed across multiple residents' rooms, indicating a systemic issue in the facility's handling of respiratory care equipment. Staff also failed to ensure that two residents had orders for oxygen therapy. For instance, Resident #6 was observed using oxygen at night without a current order for oxygen in their Physician Order Sheet (POS). Similarly, Resident #105, who was on continuous oxygen, did not have an order for oxygen in their POS. This lack of proper documentation and orders for oxygen therapy further highlights the facility's failure to adhere to proper respiratory care protocols. Interviews with staff, including CNAs, LPNs, and the Director of Nursing (DON), revealed a lack of knowledge and adherence to the facility's policies regarding the storage and maintenance of respiratory care equipment. Staff were unaware of the proper procedures for storing oxygen tubing, nebulizer masks, and CPAP/BiPAP machines, leading to inconsistent practices and potential risks of infection for the residents. The DON and other staff members acknowledged the deficiencies and the potential for resident infections due to improper storage and handling of respiratory care equipment.
Failure to Accurately Count Controlled Medications and Remove Expired Supplies
Penalty
Summary
Facility staff failed to accurately count controlled medications for two residents. For Resident #13, the controlled medication record indicated 27 Hydrocodone APAP 5-325 mg tablets, but observation showed 28 tablets. Similarly, for Resident #16, the record indicated five tablets, but observation showed six tablets. An LPN admitted to taking shortcuts and not counting the actual pills due to being in a hurry. The DON and the administrator confirmed that staff should count both the cards and the pills at each shift change and notify the DON if the count is incorrect, which did not happen in this case. Additionally, the facility staff failed to remove and destroy expired medications and medical supplies. Expired items found in the medication storage room included Clearlax Polyethylene Glycol 3350 Powder and 51-25 gauge safety needles. The LPN responsible for monitoring the medication room admitted to not knowing that needles could expire and was unsure how the expired items were missed. The DON and the administrator confirmed that staff should check medication rooms and carts for expired medications weekly, which was not done properly in this instance.
Failure to Provide Appropriate Discharge Notice and Readmission
Penalty
Summary
The facility staff failed to provide an appropriate 30-day discharge notice for a resident and did not allow the resident to return to the facility after being discharged from the hospital. The facility's Discharge/Transfer of Resident policy requires staff to explain the transfer and reason to the resident and/or representative and provide a copy of the transfer or discharge notice. In the case of an emergency transfer, the notice form may be completed later but as soon as possible. However, the resident's medical record did not contain an emergency or 30-day discharge notice prior to discharge, and the resident was not provided with an acceptance of admission to an alternative facility. The resident was admitted to the facility and received intravenous (IV) antibiotic medication but became weak and unsteady, leading to an order to send the resident to the emergency room. The facility staff decided not to readmit the resident, citing the inability to meet the resident's needs due to additional information received about the resident's history of drug use, wound care, and behaviors. Interviews with the facility's social services designee, administrator, and LPN revealed that the hospital had not initially provided complete information about the resident's medical history and behaviors. The hospital social worker confirmed that the resident remained in the emergency department, and placement had not yet been found for the resident.
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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