Clark County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Kahoka, Missouri.
- Location
- 1260 North Johnson Street, Kahoka, Missouri 63445
- CMS Provider Number
- 265485
- Inspections on file
- 13
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Clark County Nursing Home during CMS and state inspections, most recent first.
A resident with a history of constipation, hemorrhoids, iron deficiency anemia, and opioid use experienced severe difficulty with bowel movements and rectal pain. An RN twice assessed the resident, found a large fecal impaction, and digitally removed the mass, but did not document the event or notify the physician. In the following days, the resident developed ongoing rectal bleeding and appeared pale, tired, and weak. Although a CBC was ordered after the bleeding was reported, staff were unable to obtain the blood sample for several days and did not notify the physician of this failure or the resident’s worsening condition until after critical lab results were finally obtained, at which point the resident was sent to the hospital.
Facility staff performed a urinary catheterization and urine drug screen on a cognitively intact resident without obtaining consent from the resident or their emergency contact and without a physician order for the drug screen. The DON conducted these procedures based on observed changes in the resident's condition and behavior, but there was no documentation of urinary retention or notification to the physician or family. Interviews confirmed that consent and proper orders were not obtained, and the facility lacked a policy for such procedures.
The facility failed to properly label and manage food items in storage and maintain cleanliness of food service equipment. Observations showed unlabeled and expired food items in storage, and a buildup of debris on the ice machine and dishwasher. Interviews revealed inconsistencies in staff responsibilities and cleaning schedules, contributing to these deficiencies.
The facility failed to follow infection control standards during blood glucose monitoring and did not properly store oxygen tubing and nebulizer equipment, leading to potential contamination risks. Additionally, the facility lacked a comprehensive Legionella control policy, failing to conduct a water assessment or develop a management program in line with CDC and ASHRAE standards.
The facility failed to complete federally mandated Significant Change in Status Assessments (SCSA) for four residents who experienced significant changes in their conditions. These residents showed declines in activities of daily living, weight loss, and new health issues, yet the required assessments were not performed. Interviews revealed a lack of adherence to guidelines, contributing to the deficiency.
The facility failed to follow proper medication administration techniques for insulin pens and eye drops for three residents. An RN did not wait the recommended time after administering insulin to two residents with diabetes, and a CMT did not apply pressure or instruct a resident to keep their eyes closed after administering ketotifen eye drops. These actions were inconsistent with the manufacturers' guidelines.
The facility failed to ensure safe wheelchair propulsion for three residents, leading to potential accident hazards. A resident with severe cognitive impairment was propelled without foot pedals, causing their feet to slide on the floor. Another resident, dependent on staff for long-distance mobility, was also propelled without foot pedals, struggling to keep their feet off the ground. A third resident's foot dragged on the floor while being pushed by staff. The DON and Administrator acknowledged the need for foot pedals to prevent injuries.
The facility failed to conduct necessary assessments and obtain informed consent for the use of bed rails for several residents, leading to deficiencies in care. A resident with severe cognitive impairment used side rails without documented assessment or consent. Another resident used side rails for mobility and boundary limitations without documented risk assessment or consent. A third resident had consent from a family member but lacked a documented entrapment risk assessment. The DON acknowledged the lack of documentation and consent.
The facility failed to properly label and dispose of medications, and did not securely store controlled substances. Insulin for two residents was not dated or discarded within 28 days, and Ativan was not stored in a locked compartment. Expired medications were not timely destroyed, including those of a deceased resident. Staff interviews revealed inconsistent responsibility for medication checks.
A facility failed to assess pressure alarms as restraints for a resident with severe cognitive impairment and a history of falls. The resident expressed agitation and a feeling of being restrained by the alarms, which were intended to prevent falls. Despite the resident's distress and attempts to disable the alarms, the facility did not evaluate their use as restraints. Interviews revealed the resident felt restricted and fearful, while the facility's leadership did not consider the alarms to be restraints.
Two residents in an LTC facility received inadequate pressure ulcer care, leading to deficiencies in their treatment and care plans. One resident developed an unstageable pressure ulcer on the right heel, with staff failing to update the care plan or implement proper interventions. Another resident had multiple pressure ulcers, with the facility failing to maintain the low air loss mattress at the correct weight setting. Observations and staff interviews revealed a lack of communication and oversight in implementing and maintaining appropriate interventions.
A facility failed to provide restorative nursing services to a resident who developed contractures in the knees and hips, despite being admitted without such limitations. The resident, with severe cognitive impairment and other diagnoses, became dependent on staff for several activities. The facility lacked a system to identify and prevent contractures, and the resident was not included in the restorative nursing program, nor were there orders for physical therapy evaluation or treatment.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan lacked specific interventions for PTSD triggers. The resident avoided communal areas due to feeling overwhelmed, and staff relied on word of mouth to learn about triggers, which were not documented in care plans. The DON confirmed the absence of a trauma-informed care policy.
The facility failed to provide written notices of transfer to two residents when they were transferred to the hospital. One resident with moderate cognitive impairment was admitted with COVID-19 and hip pain, while another was transferred twice due to medical issues, including cardiac dysrhythmia. The Director of Nursing and Administrator were unaware of the requirement for written notices, and staff only verbally informed families of transfers.
The facility failed to provide a written bed hold policy notice to residents or their representatives during hospital transfers. This deficiency was identified for three residents who were transferred for medical evaluation and treatment. Interviews revealed that the facility did not issue bed hold notices, claiming they take all residents back and were unaware of the requirement.
Failure to Document Digital Fecal Impaction Removal and Notify Physician of Bleeding and Delayed Labs
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of quality by not documenting a significant procedure, not promptly notifying the physician of changes in condition, and not communicating inability to obtain ordered labs for one resident with constipation and hemorrhoids. The resident had a history of constipation, hemorrhoids, and iron deficiency anemia, and was receiving multiple laxatives, hemorrhoid treatments, low-dose aspirin, an iron supplement, and an opioid (tramadol). A Significant Change MDS from the prior month documented moderately impaired cognition, maximum assistance for toileting and transfers, and no constipation. Facility policy required prompt physician notification and documentation in the medical record when there were changes in a resident’s condition or a need to significantly alter treatment. On 1/11/26, the resident experienced severe difficulty having a bowel movement and reported feeling fecal material stuck in the rectum, causing pain. A CNA reported this to an RN, who assessed the resident twice that day. The RN found the rectum dilated with a firm, softball-sized fecal mass and, after initial lubrication and reassessment, digitally removed the fecal impaction in several passes, after which the resident passed additional loose stool. The RN later acknowledged not documenting the impaction, the digital removal procedure, or the resident’s complaints in the nurse’s notes, and did not notify the physician of the impaction or the intervention, stating he/she did not believe it was necessary because the resident was not bleeding and was able to have a bowel movement afterward. Nurse’s notes for that date contained no record of the impaction, the resident’s pain, or the digital removal. On 1/13/26, nurse’s notes documented rectal bleeding that continued even without bearing down, and administration of a hemorrhoidal suppository. On 1/14/26, the nurse documented speaking with the physician about bleeding hemorrhoids and blood loss, and a CBC was ordered; however, staff were unable to obtain the blood sample and there was no documentation that the physician was notified of this inability. On 1/16/26, notes showed the resident passed a bright red rectal clot larger than a quarter and then a large amount of dark blood, with the DON notified and a hemorrhoidal suppository given. The DON attempted multiple blood draws without success, and later that evening the resident was documented as very pale, tired, and weak, but there was still no documentation that the physician was notified of these changes or of the continued inability to obtain the ordered lab. The CBC was finally obtained on 1/17/26, and the lab reported a critically low hemoglobin of 5.5 g/dL and critically high white blood cell count to the charge nurse, after which the physician was notified and the resident was sent to the hospital. In interviews, the DON confirmed she did not notify the physician about the failed lab draws until 1/17/26, and the physician stated his expectation that he be notified when manual fecal removal is performed and when staff are unable to obtain ordered labs.
Failure to Obtain Consent for Urinary Catheterization and Drug Screen
Penalty
Summary
Facility staff failed to honor a resident's rights by performing a urinary catheterization and obtaining a urine drug screen without notifying or obtaining permission from the resident or their emergency contact. The resident was documented as cognitively intact, alert, and oriented, and was their own responsible party. The facility's policy states that residents have the right to be fully informed about their care and to make decisions regarding their treatment, including the right to refuse care and to have their physician and family notified of significant changes. The resident's medical record showed an open-ended order for straight catheterization as needed for urinary retention, but there was no documentation of urinary retention at the time of the procedure, nor was there a physician order for urine collection or drug screening. Nursing notes indicated that the Director of Nursing (DON) performed the straight catheterization and drug screen based on observed changes in the resident's condition and behavior, as well as reports of possible marijuana use. However, there was no documentation that the resident or their emergency contact was informed or gave consent for these procedures, and no physician order was obtained for the drug screen. Interviews with facility staff, including the DON and the Administrator, confirmed that no permission or physician order was obtained prior to the procedures. The DON acknowledged that she should have obtained consent from the resident or their emergency contact and that the facility lacked a policy for obtaining drug screens or following physician orders for such procedures. The resident's physician also stated that staff should probably get permission before performing a urine drug screen.
Deficiencies in Food Labeling and Equipment Maintenance
Penalty
Summary
The facility failed to properly label and manage food items in both the dry storage and walk-in cooler areas. Observations revealed that several food items, such as cornflakes, pork gravy mix, and cheddar cheese sauce mix, were opened and resealed without proper labeling of opened dates or expiration dates. Additionally, prepared food items like egg salad and tomato sauce in the walk-in cooler were not discarded after their labeled use-by dates. Interviews with the Dietary Manager and Supervisor confirmed that dietary staff were expected to label food items correctly and remove expired items, but these practices were not consistently followed. The facility also failed to maintain cleanliness and proper maintenance of food service equipment, specifically the ice machine and dishwasher. Observations showed a buildup of white scaly material and rust-colored run marks on the ice machine, as well as debris accumulation on the dishwasher's surfaces and piping. The Dietary Manager and Supervisor indicated that dietary staff were responsible for cleaning these machines, but there was uncertainty about the frequency of cleaning. The Maintenance Technician was unaware of the condition of the ice machine and stated that it was due for cleaning. Interviews with the Administrator highlighted that both the dietary and maintenance departments were responsible for ensuring the cleanliness and proper labeling of food items and equipment. However, the lack of consistent monitoring and adherence to cleaning schedules contributed to the deficiencies observed. The Administrator expected staff to label food items when opened and remove items past their use-by dates, as well as maintain clean and sanitized equipment areas.
Infection Control and Legionella Management Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards during blood glucose monitoring for three residents. Staff did not appropriately sanitize the glucometer after use, nor did they use a barrier to prevent contamination. The glucometer was cleaned with alcohol wipes instead of the recommended Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipes, as per the manufacturer's instructions. This improper cleaning method was due to incorrect guidance from nurse managers, as reported by the staff involved. Additionally, the facility did not store oxygen tubing and nebulizer equipment properly when not in use, leading to potential contamination risks for three residents. Oxygen tubing was found lying on the floor or bed without being stored in a protective bag, and nebulizer equipment was left uncovered on surfaces. Staff interviews revealed a lack of awareness and adherence to proper storage protocols, contributing to the deficiency. The facility also lacked a comprehensive policy for Legionella control, failing to conduct a facility water assessment or develop a water management program in line with CDC and ASHRAE standards. The facility's policy did not include a water management team, a water flow map, or specific control parameters for water monitoring. Interviews with staff indicated a lack of knowledge and implementation of necessary measures to prevent Legionella growth, further contributing to the deficiency.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for four residents, despite significant changes in their conditions. This assessment is federally mandated and should be completed within 14 days after a significant change in a resident's physical or mental condition that impacts more than one area of their health status. The report highlights that the facility did not perform these assessments for four residents out of a sample of 22, despite observable declines in their activities of daily living (ADL) and other health indicators. Resident #18 experienced a decline in ADL functions, requiring increased assistance for oral hygiene, dressing, and transfers, and became occasionally incontinent of bowel. Despite these changes, no SCSA was completed. Similarly, Resident #8 showed a decline in independence, requiring more assistance in various ADL areas, experienced significant weight loss, and developed a new swallowing disorder, yet no SCSA was documented. Resident #13 also had changes in hearing, range of motion, and required more assistance in ADL areas, but again, no SCSA was completed. Resident #28 had changes in mobility, weight, and required more assistance in ADL areas, with new pain management interventions, but the facility did not complete an SCSA. Interviews with the MDS coordinator and the Director of Nursing revealed a lack of understanding and adherence to the RAI manual guidelines, contributing to the failure to complete the necessary assessments. The MDS coordinator admitted to not using the RAI manual properly, and the Director of Nursing expected the SCSA to be initiated within a few days of a change, but this was not done as required.
Improper Medication Administration Techniques
Penalty
Summary
The facility failed to adhere to proper medication administration techniques for insulin pens and eye drops for three residents. Resident #58, diagnosed with diabetes mellitus, received an insulin injection from RN B who did not wait for the recommended count of six after administering 40 units of Tresiba insulin. Similarly, Resident #2, also with diabetes mellitus, was administered eight units of Humalog insulin by RN B, who again did not wait for the recommended count of five after administration. These actions were contrary to the administration instructions provided by the manufacturers of the insulin pens. Additionally, Resident #21, who had an order for ketotifen eye drops for allergic conjunctivitis, did not receive the medication according to professional standards. CMT C administered the eye drops without applying pressure to the lacrimal gland or instructing the resident to keep their eyes closed for the recommended two to three minutes. This was inconsistent with the administration guidelines for ketotifen ophthalmic eye drops. Both RN B and CMT C acknowledged their deviations from the expected procedures during interviews.
Failure to Use Wheelchair Foot Pedals Poses Accident Hazards
Penalty
Summary
The facility failed to ensure that three residents in wheelchairs were propelled safely, leading to potential accident hazards. Resident #28, who had severe cognitive impairment and was dependent on wheelchair mobility, was observed being propelled by a CNA/CMT without foot pedals on the wheelchair. The resident's feet slid on the floor, creating a sliding sound, and the staff did not apply foot pedals or ensure the resident's feet were safe, despite being instructed to always use foot pedals to prevent injury. Resident #17, who had moderate cognitive impairment and was dependent on staff for wheelchair mobility over long distances, was also propelled without foot pedals. The resident struggled to keep their feet off the ground, causing the wheelchair to stop when their feet hit the floor. Despite the resident's care plan indicating the need for staff assistance with long-distance wheelchair mobility, staff did not use foot pedals, citing busyness as a reason for not retrieving them. Resident #11, who used a wheelchair for mobility and had a history of falls, was pushed by the Social Services Director without foot pedals. The resident's foot dragged on the floor during the transport, which the staff did not notice. The Director of Nursing and the Administrator acknowledged that staff should not propel residents without foot pedals, especially over long distances, and that foot pedals were available in bags on the wheelchairs.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete necessary assessments and obtain informed consent for the use of bed rails for several residents, leading to deficiencies in care. Resident #17, who had severe cognitive impairment and a history of falls, was using one-fourth side rails for assistance with bed positioning. However, there was no documentation of a side rail assessment or an assessment of the resident's risk for entrapment prior to the use of the side rails. The Director of Nursing (DON) acknowledged that while she completed a mental assessment, she did not document it, intending to do so at a later date. Resident #54, who also had severe cognitive impairment and required substantial assistance for mobility, was using one-fourth side rails for bed mobility and boundary limitations. The facility did not document an assessment of the resident's risk for entrapment, nor did they obtain consent from the resident or family for the use of the side rails. The DON admitted that she could not find a consent form for the resident and explained that the resident used the side rail to identify the edges of the bed. Resident #18, with a history of falls and severe cognitive impairment, was using one-fourth side rails for assistance and boundary limitations. Although a family member had signed a consent form, there was no documentation of an assessment for the risk of entrapment. The resident's care plan indicated the use of side rails for assistance, but the facility failed to document the necessary assessments prior to their use. The DON confirmed that assessments should be completed before using side rails and that consent should be obtained beforehand.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of medications, as well as secure storage of controlled substances. Insulin vials and pens for two residents were not dated when opened, and one insulin vial was not discarded within the designated 28-day period after opening. Additionally, a schedule IV controlled substance, Ativan, was not stored in a separately locked compartment as required, and expired medications were not destroyed in a timely manner. Specifically, a bottle of liquid Ativan was found in an unlocked refrigerator, and expired Xanax tablets were found in the emergency narcotic box. Further observations revealed that expired medications belonging to a deceased resident were not destroyed, including albuterol sulfate inhalation solutions and nystatin topical powder. Interviews with staff indicated that there was a lack of consistent responsibility for checking and disposing of expired medications, with the Licensed Practical Nurse and Director of Nursing acknowledging that all nursing staff should be involved in this process. The facility's failure to adhere to medication management protocols resulted in deficiencies related to medication labeling, storage, and disposal.
Failure to Assess Pressure Alarms as Restraints
Penalty
Summary
The facility failed to assess the use of pressure alarms as a restraint for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted to the facility due to repeated falls at home, was equipped with pressure alarms on both the bed and chair as a fall prevention measure. Despite the alarms being intended for safety, the resident expressed agitation and a feeling of being restrained, as documented in staff notes and interviews. The resident's medical history included dementia with behavioral disturbances, Parkinsonism, and major depressive disorder, among other conditions. The resident required assistance with mobility and had a durable power of attorney for healthcare decisions. Despite the resident's severe cognitive impairment, there was no evidence that the facility evaluated the use of the alarms as a restraint, even after the resident expressed distress and attempted to disable the alarms. Interviews with the resident and their spouse revealed dissatisfaction with the alarms, which the resident felt restricted their freedom and caused fear of getting up. The Director of Nursing and the Administrator did not consider the alarms to be restraints, as they believed the alarms did not prevent movement. However, the resident's repeated expressions of feeling trapped and the lack of a documented assessment of the alarms as restraints highlight a deficiency in the facility's approach to the resident's care.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment and care plans. Resident #42, who had severe cognitive impairment and a diagnosis of diabetes mellitus, osteoporosis, and dementia, developed an unstageable pressure ulcer on the right heel. The facility staff did not update the resident's care plan to include the new wound or the intervention to float the resident's heels. Observations showed that the resident's heels were pressed against a pillow, contrary to the care plan, and the bed did not have a pressure-reducing mattress as documented. The resident experienced pain during wound care, and the wound was not treated with Betadine as ordered. Resident #1, with severe cognitive impairment and diagnoses of Alzheimer's disease, dementia, and anxiety disorder, had multiple pressure ulcers, including on the right buttocks and elbow. The facility failed to maintain the low air loss mattress at the correct weight setting, which was overinflated and too firm for the resident's weight. The care plan did not document the development of new open areas or the discontinuation of the feather tick mattress and addition of an air mattress. Observations confirmed the mattress was consistently set too high, and the resident's wounds showed signs of worsening. Interviews with staff, including the Wound Care Nurse and the Director of Nursing, revealed a lack of communication and oversight in implementing and maintaining appropriate interventions for pressure ulcer care. The Wound Care Nurse was responsible for overseeing wound care and quality measures but acknowledged gaps in ensuring interventions were followed. The Director of Nursing expected staff to ensure proper mattress settings and heel positioning, but these expectations were not met, contributing to the deficiencies in care for both residents.
Failure to Provide Restorative Nursing Services for Resident with Contractures
Penalty
Summary
The facility failed to provide restorative nursing services to a resident who was initially admitted without contractures and had no limitations in range of motion. Over time, the resident developed contractures in the knees and hips, which were not addressed by the facility's restorative nursing program. The facility lacked a system to identify residents at risk for decreased range of motion or to prevent the development of contractures. The Director of Nursing confirmed that there was no policy in place for range of motion, contractures, or their prevention and improvement. The resident, who had severe cognitive impairment and diagnoses including heart dysrhythmia and diabetes mellitus, was initially independent in many activities of daily living. However, as the resident's condition changed, they became dependent on staff for several activities and developed contractures in both knees. Despite these changes, the resident was not included in the facility's restorative nursing program, and there were no physician orders for physical therapy evaluation or treatment. Observations showed the resident in a fetal position with contractures, and staff confirmed the resident's contracted state.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement a system to ensure trauma-informed care for residents with PTSD, as evidenced by the case of a resident with PTSD and major depressive disorder. The resident's care plan lacked specific interventions to address PTSD triggers, and there was no documentation of trauma-informed care assessments in the resident's medical record. The resident expressed that the facility did not provide counseling and that he/she avoided the dining room and group activities due to feeling overwhelmed by commotion. The facility's Director of Nursing confirmed the absence of a policy for trauma-informed care and acknowledged that staff were still learning about residents' triggers, which were not consistently documented in care plans. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that the facility did not have specific interventions for residents with PTSD and relied on word of mouth to communicate residents' triggers. The MDS Coordinator was unsure if the resident's care plan included PTSD-related behavioral issues, and the DON admitted that triggers and behaviors were not systematically monitored or included in care plans. The Administrator stated that all residents were treated as if they had PTSD, but the lack of formalized procedures and documentation indicated a deficiency in providing trauma-informed care.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a written notice of discharge with the required information to two residents when they were transferred to the hospital. Resident #13, who had moderate cognitive impairment, was sent to the hospital with a high fever and was admitted with COVID-19 and hip pain. There was no documentation in the resident's medical record indicating that a written notice of transfer was issued to the resident or their representative. Similarly, Resident #48, who had a durable power of attorney for healthcare decisions, was transferred to the hospital on two occasions due to medical issues, including a cardiac dysrhythmia and syncopal episodes, but no written notice of transfer was provided to the resident's representative. During interviews, the Director of Nursing and the Administrator acknowledged that the facility did not issue written notices of transfer for facility-initiated transfers and were unaware of the requirement to do so. The Director of Nursing stated that staff verbally informed families when a resident was going to the hospital but did not provide information on how to appeal the transfer, ombudsman contact information, or information on mental health advocacy. The facility's failure to provide written notices of transfer with the required information was identified as a deficiency during the survey.
Failure to Provide Bed Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to residents or their representatives when residents were transferred to the hospital for medical evaluation and treatment. This deficiency was identified for three residents out of a sample of 22. Resident #13, who had moderate cognitive impairment, was sent to the hospital with a high fever and was diagnosed with COVID-19 and hip pain. There was no documentation that the resident or their representative received a bed hold policy notice upon hospital admission. Similarly, Resident #61, who had a durable power of attorney for healthcare, was sent to the hospital due to shortness of breath, and no bed hold policy notice was documented. Resident #48, also with a durable power of attorney, was transferred to the hospital twice for medical issues, including a cardiac dysrhythmia, but again, no bed hold policy notice was provided. Interviews with the Director of Nursing and the Administrator revealed that the facility did not issue bed hold policy notices because they claimed to take all residents back and were unaware of the requirement to provide such notices during transfers or discharges. This lack of awareness and failure to provide the necessary documentation led to the deficiency being cited by surveyors.
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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