Colonial Springs Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo, Missouri.
- Location
- 750 West Cooper, Buffalo, Missouri 65622
- CMS Provider Number
- 265245
- Inspections on file
- 16
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Colonial Springs Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognition and dependence on staff for ADLs, including toileting and use of a sit-to-stand lift, reported that a CNA became frustrated with the lift during bathroom assistance and cursed using the "f" word in the resident’s room. The resident felt the language was inappropriate and reported the incident to an LPN, the Social Service Director, and then the Administrator. Facility policy states residents have the right to be treated with dignity and respect, and in interviews the CNA, other CNAs, the DON, and the Administrator all acknowledged that cursing around residents is disrespectful and not acceptable.
A resident with a hip fracture diagnosis and intact cognition experienced multiple room transfers between different halls, but the facility failed to provide and document required written notice before these room changes. Facility policies required prompt written and advance notice to the resident and, when applicable, the representative for any room or roommate transfer. Registration records showed several room changes, yet only one room/roommate change notice form was found, and staff interviews (including SSD, CNA, LPN, DON, and the Administrator) confirmed that while notification and documentation were expected practices, there was no documentation of notifications for several of the resident’s room moves.
A resident with a history of hip fracture experienced a fall while attempting an independent transfer from a wheelchair to bed. Staff responded, initially noted no injury, and obtained STAT X‑rays of the resident’s right upper extremity, which later showed findings consistent with a radial neck fracture of indeterminate age. Although facility policy required timely notification and documentation of changes in condition, accidents, injuries, and diagnostic results to the physician, resident, and family/responsible party, the medical record contained no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. In interviews, an LPN, an RN, the DON, and the Administrator all confirmed that such notification and documentation were expected but had not occurred in this case.
The facility failed to maintain a complete and timely grievance process for a resident and the resident’s family member, despite multiple complaints about care, use of briefs instead of pullups, missing personal items, and a reported $10 payment to an aide. Although the facility’s policy required escalation of unresolved complaints, maintenance of a grievance log, and written notice of investigation results, staff did not consistently enter grievances on the log, did not document follow-up steps or resolutions, and did not obtain or record confirmation from the complainant. Progress notes and interviews with the SSD, DON, and Administrator showed that some grievances were only partially documented, some were omitted from the log entirely, and outcomes of certain investigations were unknown or not recorded, resulting in an incomplete grievance process for the resident’s concerns.
The facility failed to complete a required baseline care plan within 48 hours of admission for a resident admitted with multiple pelvic fractures who required assistance with toileting, hygiene, bathing, and lower body dressing. Policy required licensed nursing staff to complete admission assessments within 24 hours and initiate a nursing care plan based on identified needs, using an electronic template that includes admission status, responsible party information, and medications. Record review showed no baseline care plan in the resident’s chart, and interviews with the MDS RN, an MDS LPN, RN staff, the DON, and the Administrator confirmed that the admitting or on-duty nurse was responsible for this task, that an admission audit process existed to flag incomplete paperwork, and that staff believed the care plan had been completed when it had not.
Staff failed to maintain safe transfer practices when one resident was jostled in a sit‑to‑stand mechanical lift and another was transferred without a gait belt. In the first case, a cognitively intact resident with prior ankle injury, weakness, and fall risk reported that a CNA became frustrated when a sit‑to‑stand lift got stuck on damaged flooring, repeatedly raising and lowering the lift so the resident swayed and experienced chest soreness and fear. Other staff confirmed the lift frequently got stuck on a notch in the floor, and maintenance reported the floor had sunk after a lift was placed on it too soon, but no work orders had been submitted about the lift wheels locking up. In the second case, a resident with severe cognitive impairment and total dependence for mobility was observed being transferred from bed to wheelchair by a CNA who did not use an available gait belt, instead lifting and pivoting the resident by holding around the back. The CNA believed the resident was care planned not to use a gait belt, while multiple CNAs, therapy staff, nursing staff, the DON, and the Administrator all stated that gait belts should always be used for such transfers and that this resident was not exempt from gait belt use.
The facility failed to administer time-sensitive medications as ordered and within policy-defined time frames for two residents. One resident on apixaban and flecainide had BID and Q12H doses that were either undocumented or given at widely varying times, without corresponding nursing notes explaining missed or late doses. Another resident with a sacral pressure ulcer and on anticoagulant therapy had metoprolol ordered for early morning administration but consistently received it several hours later, again without documentation of the variance. Staff interviews, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, showed inconsistent understanding of the liberalized medication pass and which medications were exempt, contributing to inconsistent adherence to ordered administration times.
The facility failed to prevent possible food contamination due to improper storage and preparation practices. The ice machine had microbial growth, a dented can of pumpkin was stored for use, and scoops were improperly left in containers of sugar and cornstarch. Staff were unclear about responsibilities and proper procedures, leading to potential contamination risks.
The facility failed to maintain a sanitary environment by not ensuring the cleanliness of fans in the walk-in refrigerator and freezer, as black and brown substances were observed on the fan casings. There was no policy or clear responsibility for cleaning these fans, leading to confusion among dietary and maintenance staff about their roles in maintaining cleanliness.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, affecting five residents. Despite the policy requiring notification upon admission and within 24 hours of an emergency transfer, documentation was lacking. Interviews revealed inconsistent practices and a lack of awareness among staff regarding the distribution of the bed hold policy.
The facility failed to document physician orders for catheter placement and care for two residents, leading to deficiencies in catheter management. One resident had severe cognitive impairment and an indwelling catheter without documented orders, while another returned from the hospital with a catheter but lacked documented orders until days later. Staff interviews revealed inconsistencies in the process of obtaining and documenting these orders.
The facility failed to ensure proper pharmacy services for controlled substances, as staff did not consistently document medication counts and administration on controlled drug record logs. Instances included single staff signing shift count sheets and discrepancies in tablet counts for residents. Interviews revealed non-compliance with policy, as some staff did not perform counts with another member and occasionally passed narcotics without verification.
A facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter to a resident upon discharge from Medicare Part A services. The resident, who needed to stay in the facility for further care, did not receive documentation of estimated costs for non-covered services and had to research these costs independently. The Social Services Director and Administrator acknowledged the oversight, as the SNFABN was not issued due to a misunderstanding of the requirements.
Facility staff failed to complete quarterly MDS assessments for two residents within the required 92-day timeframe due to a glitch in the tracking system. The MDS Coordinator, who was primarily responsible for assessments, and the Assistant MDS Coordinator, who recently began assisting, confirmed the oversight. The Administrator was unaware of the tracking system and the untimely assessments.
A resident with a history of subarachnoid hemorrhage and diabetes required tube feeding, but the facility failed to administer it consistently as ordered. Observations showed the feeding was often not attached or running, and staff interviews revealed confusion about the feeding schedule. The facility's policy required adherence to physician orders, but unclear orders led to inconsistent feeding administration.
The facility failed to maintain a medication error rate below 5%, with errors involving the improper timing of levothyroxine administration for two residents. The medication was given after breakfast and with other medications, contrary to orders for it to be taken at 6:00 A.M. on an empty stomach. Staff interviews confirmed awareness of the issue, but cited challenges in adhering to the schedule due to the number of residents.
A facility failed to report an incident of inappropriate touching between two residents to the state agency within the required timeframe. The incident involved a resident with cognitive impairment and another with a history of bipolar disorder and dementia. Staff interviews revealed inconsistencies in understanding reporting requirements, with some staff unsure if the incident constituted abuse. The DON and Administrator provided conflicting views on the necessity of reporting, leading to the facility's failure to comply with its abuse/neglect policy.
The facility failed to investigate an incident where a resident was found touching another resident's genitalia, contrary to its abuse/neglect policy. Despite the policy requiring immediate investigation and documentation, no formal investigation was conducted, and the incident was not reported to the DHSS. Interviews revealed staff uncertainty in handling such situations, and the facility did not verify consent from the involved residents.
Failure to Maintain Resident Dignity When CNA Used Profanity During Care
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to be treated with dignity and respect when a CNA used disrespectful and profane language in the resident’s presence. The facility’s Resident Rights policy, revised 10/01/21, states that residents have the right to be treated with dignity and respect. The affected resident had been admitted with a diagnosis including dislocation of the right ankle joint and, per the quarterly MDS dated 02/20/26, had intact cognitive skills, no documented behaviors, was dependent for toileting and personal hygiene, and required substantial/maximal assistance with showering. The resident’s care plan, reviewed 02/26/26, documented that the resident required extensive to total assistance with one to two staff for all ADLs and directed staff to use a calm, reassuring approach. On the evening of 02/14/26 at approximately 9:30 P.M., the resident reported that while being assisted to the bathroom with a sit-to-stand lift that was hard to turn, CNA F became frustrated with the equipment and cursed, using the “f” word, in the resident’s room. The resident stated they did not feel the CNA’s language was appropriate and felt the CNA used inappropriate language. The resident reported the incident to an LPN and the Social Service Director, who told the resident to inform the Administrator; the resident then went to the Administrator’s office and reported that the CNA was mad at the sit-to-stand lift and cursed. In interviews, the Administrator acknowledged receiving a delayed report that the resident thought the CNA was unprofessional and did not appreciate the language. CNA F stated that cursing around a resident is not respectful and is a form of abuse, and other staff, including another CNA, the DON, and the Administrator, all stated that staff should not curse around residents and that staff are expected to be respectful.
Failure to Provide and Document Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide and document written notice to a resident before multiple room changes, contrary to its own policies on room and roommate transfers and notification guidelines. The facility’s policies required prompt written notification to the resident and, when applicable, to the resident’s representative for any change in room or roommate assignment, as well as advance notice of such transfers. Resident #1, admitted with a diagnosis including a fracture of the neck of the left femur and assessed as cognitively intact on the MDS, experienced several room changes between different halls. Registration records showed the resident was admitted to a room on the 100 hall, then transferred to the 200 hall, later moved back to the 100 hall for quality-of-care purposes, and then again transferred to the 200 hall. Record review showed only one room/roommate change notice form dated 04/18/25 for a move to the 100 hall, and no documented room/roommate change notices for the other room changes. The Social Service Director reported that staff typically call the family or speak with the resident regarding room changes, provide a room/roommate change request card, and do not move residents if they do not want to move, but she could not find documentation of notifications for the resident’s moves back to the 200 hall. CNA and nursing staff interviews indicated that social services are responsible for informing residents of room changes and that staff should document room changes and consent in progress notes, but such documentation was absent in this case. The DON and Administrator both stated that staff are expected to document room changes and resident/family notification in the progress notes, yet this was not done for Resident #1, resulting in noncompliance with the requirement to provide written notice before room changes.
Failure to Notify Family/Responsible Party of Fall and X‑ray Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of a resident’s family or responsible party of a change in condition following a fall and subsequent diagnostic findings. Facility policy revised in January 2025 required that physicians, residents, and families be notified in a timely manner of clinical and environmental changes, including accidents or injuries, and that such notifications be documented. Resident #1, admitted with diagnoses including a left femur neck fracture, experienced a fall when attempting to transfer independently from a wheelchair to bed. A CNA heard a crash, found the resident sitting on the floor, and staff assessed the resident with no injuries initially noted. A nurse obtained a STAT order from a nurse practitioner for X‑rays of the resident’s right shoulder, humerus, elbow, forearm, and wrist, and the X‑rays were completed as ordered. X‑ray reports from the same day documented soft tissue swelling and changes along the radial neck suggesting a fracture of indeterminate age, with an impression of an abnormal radial neck region. A later progress note described that after the fall the resident complained of right arm pain, an X‑ray showed a radial neck fracture of indeterminate age, and that the medical director and orthopedic physician were aware and ordered a sling. However, there was no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. During interviews, an LPN, an RN, the DON, and the Administrator each stated that staff are expected to notify the resident and/or responsible party of falls, injuries, and X‑ray results and to document this notification in the progress notes, but they acknowledged that such documentation was not present for this resident.
Failure to Maintain Complete and Timely Grievance Documentation for Resident and Family Complaints
Penalty
Summary
The deficiency involves the facility’s failure to implement a complete and consistent grievance process, including timely documentation of grievances, follow-up steps, and resolutions for a resident and the resident’s family member. The facility’s grievance policy states that residents or their representatives may register complaints or grievances without fear of reprisal, and that grievances include complaints about care, abuse or neglect, and other issues that are not resolved at the time of the complaint by staff present. The policy further requires that unresolved complaints be escalated to supervisors, the Patient Advocate, and the Administrator as needed, and that the Patient Advocate maintain a log of complaints and grievances, with written notice to the complainant at the completion of the investigation, including steps taken, results, and date of completion. The resident involved had been admitted with a diagnosis including a fracture of the neck of the left femur and had intact cognitive skills, requiring partial to moderate assistance with toileting, showering, bathing, and personal hygiene. A nurse’s progress note documented that the resident’s family member complained to a CNA that the resident had not received breathing treatments that day and objected to the resident wearing a brief instead of a pullup. The nurse noted that management and social services were not available in the building at that time, and when the nurse later asked the family member if there were any issues needing resolution, the family member stated that everything was fine. Subsequently, the Social Services Director (SSD) documented receiving an email from the family member expressing concerns about the resident’s care, including breathing treatments and use of briefs, as well as missing personal items such as lotion, Kleenex, a turquoise ring, and a watch. The SSD shared the email with the Administrator and DON and noted that a staff member reported the family member had thrown wipes at them, and that the plan was to remove that staff member from providing care to the resident and to offer moving the resident to another hall. The facility’s complaint/concerns log recorded a complaint from the resident’s family member about missing rings, lotion, and a watch, and noted that replacement items were provided, but did not document any discussion with, or signature of, the resident or the family member who filed the grievance. A later progress note by the SSD, created weeks after the event date, described responding to another email from the family member about missing items and documented that the facility replaced multiple rings, lotion, and a watch, and informed the resident and family, but again did not reflect complete grievance documentation as required by policy. Another progress note by the DON described contacting the family member regarding concerns from the prior night, with the family member referring the DON to staff and a formal grievance before hanging up; however, this grievance was not entered on the facility’s grievance log. Interviews with the CNA, SSD, DON, and Administrator confirmed that the SSD was responsible for grievances, that staff were expected to report complaints to her, and that grievance forms and logs existed, but also revealed that the SSD did not document resolutions on the grievance log, did not have a form with a written resolution to return to complainants, and did not know the outcome of an investigation into a reported $10 payment from the resident to an aide. The DON acknowledged that resolutions of grievances were not documented, and the Administrator stated he expected documentation of who was spoken to, whether the grievance was resolved, and the response to the complainant, but these elements were missing, demonstrating the facility’s failure to maintain a complete grievance process for the resident’s grievances. Additional information from interviews further supports the incomplete grievance process. The SSD stated that if residents spoke with staff about complaints, staff should email or inform her, and that she reported grievances to the Administrator and DON and attempted to respond within 24 hours. She also reported receiving an email from the resident’s family member about an aide receiving $10 from the resident and said she informed the Administrator, but she did not document the resolution on the grievance log and did not know the results of that investigation. The DON described that grievances should be taken to social services, that grievance forms were available in a binder, and that staff discussed grievances in morning meetings with department heads, but she admitted she did not document grievance resolutions even though she believed they probably should be documented. The Administrator indicated that SSD should document who she talked with, whether the grievance was resolved, and the date, and that staff should document the response to the person who filed the grievance, yet he was not aware of the reported $10 payment. These documented omissions and inconsistencies in logging grievances, documenting follow-up steps, and recording resolutions for the resident’s and family member’s complaints constitute the identified deficiency in the facility’s grievance process. Overall, the events show that multiple complaints and concerns from the resident’s family member regarding care issues, missing personal items, and a possible financial concern were not consistently or fully documented as grievances in accordance with the facility’s own policy. The grievance log lacked entries for at least one formal grievance referenced by the family member, and existing entries did not include documentation of discussions with the complainant or confirmation of resolution. Staff interviews confirmed that there was no standardized form with a documented resolution returned to the complainant and that outcomes of certain investigations were unknown or not recorded. These actions and inactions demonstrate that the facility did not have a complete grievance process in place for this resident, as required by its policy and regulatory expectations.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete a baseline care plan within 48 hours of admission for one resident. Facility policy titled "Assessments in Long Term Care" required licensed nursing staff to initiate an admission assessment upon the resident’s arrival and complete nursing and screening assessments within 24 hours, with the nursing care plan initiated based on identified needs from that assessment. The facility’s initial care plan form was to include admission status, identification of the responsible party or resident offered a copy of the initial care plan, and information on resident medications. For the resident in question, the face sheet showed an admission date of 01/26/26 with diagnoses including multiple pelvic fractures, and progress notes documented arrival from the hospital that afternoon. The admission MDS dated the same day showed intact cognitive skills and a need for partial/moderate assistance with toileting and personal hygiene, and substantial/maximal assistance with showering, bathing, and lower body dressing. Despite these documented needs, review of the medical record showed no documentation that a baseline care plan was completed for this resident. The MDS Coordinator/RN stated that the admitting charge nurse is responsible for completing the baseline care plan upon admission, using a computer template, and that it should be completed within 24 hours along with admission notes; however, the RN confirmed there was no baseline care plan for this resident. Another MDS Coordinator/LPN reported that they perform an admission audit within 48 hours, circling incomplete items and returning them to the nurses’ desk, and acknowledged that staff did not complete the baseline care plan, though they believed it had been done and that the next nurse should complete any missing items. RN C stated nursing staff should complete the baseline care plan upon admission. The DON and the Administrator both indicated that the admitting nurse or nurse on duty is expected to complete the baseline care plan, including assessments and offering a copy to the resident and/or family, but this did not occur for the resident involved.
Unsafe Mechanical Lift Use and Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
The deficiency involves the facility’s failure to keep residents free from accident hazards and to provide adequate supervision during transfers, specifically in the use of a sit‑to‑stand mechanical lift and a gait belt. Facility policy on patient/resident handling, revised April 2025, states that safe procedures for providing care are a high priority, that handling incidents are to be analyzed for trends with appropriate follow‑up, and that employees are encouraged to report hazards and make safety suggestions. Despite this, staff actions during two separate transfer situations did not align with safe handling practices described by facility leadership and other staff. In the first incident, a cognitively intact resident with a history of right ankle dislocation, generalized weakness, dependence on staff for transfers and ADLs, pain related to a previous fracture, and risk for falls reported that a CNA became frustrated while using a sit‑to‑stand lift during a bathroom transfer. The resident stated that the lift was hard to turn and that the CNA raised and lowered the lift, letting it hit the floor while the resident hung by the arms and swayed, causing upper chest soreness and fear. The resident reported having to yell at the CNA to calm down. Interviews with the CNA confirmed that two wheels on the lift locked up when attempting to roll the resident out of the bathroom, that the lift was stuck, and that the resident began swinging in the lift, causing concern the resident might fall. Other staff, including another CNA and nursing staff, reported that the floor in the resident’s room and bathroom was “horrible,” that the lift frequently got stuck on a notch or damaged area of the floor, and that the resident had reported being jostled and scared when the CNA shook the lift to get it unstuck. The Maintenance Supervisor reported that a new floor had been installed in the resident’s room about a year earlier and that staff placed a sit‑to‑stand lift on it before the 24‑hour curing period, causing the floor to sink. He stated he had not received a work order or complaint about the lift wheels locking up, and that staff had previously indicated the lift was usable and were transporting residents across the bathroom floor. The DON and Administrator both stated that staff were expected to report issues with floors and equipment, including lift wheels locking up, and the DON acknowledged that rocking a lift back and forth to free it from a floor notch created safety issues. The CNA involved stated he was not aware whether maintenance had been informed of the lift getting stuck during the incident. In the second incident, a resident with dementia, severely impaired cognitive skills, and total dependence on staff for mobility and ADLs was observed being transferred from bed to wheelchair by a CNA without the use of a gait belt, despite a gait belt hanging on the wall next to the bed. The CNA rolled the resident to a sitting position, sat the resident on the edge of the bed, then placed both hands around the resident’s back, stood the resident, pivoted, and seated the resident in a wheelchair. In interview, the CNA stated that he or she normally used a gait belt for all residents but believed this resident was care planned not to use one due to potential resistance, and therefore did not use a gait belt during the observed transfer, even though the resident was not combative or resistant at that time. Multiple staff, including other CNAs, OT staff, an LPN, the DON, and the Administrator, stated that staff should always use a gait belt during one‑person transfers when a lift is not used, that gait belts are the safest way to transfer, and that there was nothing in this resident’s care plan indicating a gait belt should not be used. These events demonstrate that, in both cases, staff actions during transfers did not follow the safe handling expectations described by facility leadership and other staff, and that known environmental and equipment issues with the sit‑to‑stand lift and flooring were not effectively reported or addressed through the facility’s established hazard reporting processes.
Failure to Administer Time-Sensitive Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that met residents’ needs by not administering medications as ordered and not adhering to specified administration times. The facility’s own Medication Administration and Documentation policy allowed a liberalized medication pass with a three-hour window before and after scheduled times for certain oral medications, but it also stated that medications with a narrow therapeutic index, such as anticoagulants, should not be liberalized if ordered at a specific time on the MAR. The policy further indicated that medications are considered late if given more than three hours after their scheduled time and that missed doses require provider consultation. Despite this, staff did not consistently follow ordered times or document missed or late doses. For one resident admitted with multiple pelvic fractures and on anticoagulant therapy, physician orders included apixaban 5 mg PO BID and flecainide 25 mg PO every 12 hours. The MAR for a ten-day period showed missing documentation for both the morning and evening doses on certain days and administration times that varied widely from the expected BID schedule, including doses given at 7:00 A.M., 8:01 P.M., 10:17 A.M., 6:29 P.M., 12:14 P.M., 7:10 P.M., 10:00 A.M., 6:58 P.M., 10:55 A.M., and 7:15 P.M. Nurses’ notes for this period did not contain documentation explaining missed doses or doses given outside the ordered time frame. The NP stated that apixaban should be given eight hours between doses and that giving it earlier would be a medication error, while the pharmacist indicated it was typically scheduled at 9:00 A.M. and 9:00 P.M. due to its half-life. For another resident with a diagnosis including a sacral pressure ulcer and on anticoagulant medication, there was an order for metoprolol succinate 12.5 mg to be given daily at 6:00 A.M. The MAR showed that during the same review period, this medication was consistently administered much later in the morning, with times ranging from 9:20 A.M. to 11:10 A.M. Nurses’ notes contained no documentation related to these administrations occurring outside accepted time frames. Interviews with multiple staff, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, revealed inconsistent understanding of the liberalized medication pass, with varying descriptions of allowable time windows and which medications were considered time-specific, contributing to the failure to administer medications within the ordered or policy-defined time frames for these residents.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents possible contamination. Observations revealed that the ice machine's deflector shield had multiple black spots, indicating microbial growth. Despite the facility's policy requiring regular cleaning of ice machines, there was confusion among staff about who was responsible for cleaning the inside of the machine. The Maintenance Director, who was responsible for cleaning, was unaware of the black spots, and the Administrator was also not informed about the issue. Additionally, a large dented can of pumpkin was found on the shelf, which contradicts the FDA's guidelines that dented cans may present a serious potential hazard. Staff interviews revealed inconsistent practices regarding the handling of dented cans. Furthermore, scoops were found partially submerged in containers of sugar and cornstarch, which could lead to contamination. Staff members had differing opinions on whether this practice was acceptable, indicating a lack of clear guidelines or training on proper food storage practices.
Sanitation Deficiency in Walk-in Refrigerator and Freezer
Penalty
Summary
The facility failed to maintain a sanitary environment for residents and staff by not ensuring the cleanliness of fans located in the walk-in refrigerator and freezer. Observations on two separate occasions revealed black and brown substances on the plastic casings of the refrigerator and freezer fans. The facility did not have a policy addressing the maintenance of these fans, and the weekly cleaning schedule did not list staff responsible for cleaning them. Interviews with various staff members, including dietary aides, the Assistant Dietary Manager, the Maintenance Director, and the Administrator, revealed a lack of clarity and communication regarding responsibility for cleaning the fans. Dietary staff were unsure of their role in cleaning the fans, and the Maintenance Director admitted to not knowing when the fans were last cleaned, although he acknowledged that they should not have black or brown substances on them. The Administrator confirmed that maintenance was responsible for cleaning the fans, but there was no evidence of a structured process to ensure this task was completed regularly.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave. This deficiency was identified for five residents who were transferred to the hospital. The facility's policy requires that residents and their families be informed of the bed hold policy in writing upon admission and within 24 hours of an emergency transfer. However, the facility did not adhere to this policy, as evidenced by the lack of documentation showing that the bed hold policy was provided to the residents or their representatives. For Resident #32, the medical record did not contain a copy of the bed hold policy sent with the resident or to the resident's representative after the resident was transferred to the emergency room for multiple head lacerations. Similarly, for Resident #35, the facility checklist did not indicate that bed hold information was provided when the resident was transferred to the hospital following a fall and other medical issues. The same issue was noted for Resident #261, whose transfer documentation lacked any indication that the bed hold policy was provided. Interviews with facility staff revealed a lack of awareness and inconsistent practices regarding the distribution of the bed hold policy. The Business Office Manager was unaware of the bed hold policies, and the Social Services Director acknowledged that there was no written notification sent to residents or their representatives. Registered nurses and the Assistant Director of Nursing provided conflicting information about the process, indicating a systemic issue in ensuring compliance with the facility's bed hold policy requirements.
Failure to Document Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure proper catheter usage and care according to standards of practice, as evidenced by the lack of physician's orders for catheter placement and care for two residents. Resident #29, who was admitted with diagnoses including obstructive and reflux uropathy, retention of urine, and acute kidney failure, had a severe cognitive impairment and an indwelling catheter. Despite the care plan indicating the need for catheter care and assessment, there were no physician's orders documented for the indwelling catheter or its care. Resident #32, admitted with renal failure, returned from a hospital stay with a catheter due to urinary retention. However, the facility staff did not document any orders for the catheter placement or care until several days after the resident's return. Observations showed the resident with a catheter bag attached to the wheelchair, but the necessary orders were only entered into the system after the deficiency was noted. Interviews with facility staff, including RNs, CNAs, and the ADON, revealed a lack of clarity and consistency in the process of obtaining and documenting physician's orders for catheter care. Staff members indicated that orders should be entered by nurses or doctors, and that catheter care tasks appear on work lists, but there was a failure to ensure that all residents with catheters had the appropriate orders documented in their medical records.
Inadequate Documentation and Reconciliation of Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmacy services for the consistent counting, reconciliation, and destruction of controlled substances. This deficiency was identified through observations, interviews, and record reviews, revealing that staff did not consistently document the number of medication packages and doses of controlled medications at the change of shift on the controlled substance shift change log. Additionally, there was a failure to document the administration of medications on individual resident controlled drug record logs for three residents. The facility's policy required that controlled substances be counted at shift changes and discrepancies be resolved immediately, but these procedures were not consistently followed. Specific instances of non-compliance included single staff members signing the shift count sheet instead of the required two, and missing documentation for several shifts. For example, on multiple occasions, only one staff member signed the shift count sheet, and there were no documented counts for certain days. Furthermore, discrepancies were found in the controlled drug records for three residents, where the actual tablet count did not match the documented count. Interviews with staff revealed that some did not perform counts with another staff member and occasionally passed narcotics without verifying the count. The Director of Nursing (DON) and the Administrator both expressed expectations for narcotic counts to be completed at every shift change and whenever narcotic keys were exchanged. However, these expectations were not met, as evidenced by the lack of documentation and unresolved discrepancies. Staff interviews indicated a lack of adherence to the facility's policy, with some staff members admitting to not counting narcotics with another staff member and failing to document administered doses on the controlled drug record logs.
Failure to Provide SNFABN for Medicare Part A Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for a resident who remained in the facility upon discharge from Medicare Part A services. The resident, identified as Resident #49, was admitted to the facility and had a Medicare Part A skilled services episode starting on October 14, 2024, with the last covered day being December 6, 2024. The facility initiated the discharge from Medicare Part A services before benefit days were exhausted but did not provide the required SNFABN or an alternative denial letter to the resident or their legal representative. During interviews, the resident stated that they signed the Notice of Medicare Non-Coverage (CMS-10123-NOMNC) but did not receive any documentation showing the estimated cost of services that would not be covered after the last covered day. The resident had to conduct their own research to determine the daily cost of room/board and therapy, as they needed to stay in the facility until they could bear weight on their affected leg and transfer independently. The Social Services Director (SSD) and the Administrator acknowledged the oversight, with the SSD indicating that they were instructed to issue the SNFABN only if a resident was staying for long-term care, which led to the failure to provide the necessary notice to the resident.
Failure to Complete Timely MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to complete quarterly Minimum Data Set (MDS) assessments for two residents within the required 92-day timeframe. Resident #18's last MDS assessment was recorded on 07/24/24, and no subsequent assessment was documented for over 129 days. Similarly, Resident #77's last assessment was on 07/29/24, with no follow-up assessment documented for over 124 days. The facility's census was 109, and the absence of timely assessments was attributed to a glitch in the tracking system, which led to the omission of the next assessment dates for these residents. Interviews with the MDS Coordinator and Assistant MDS Coordinator revealed that until recently, the MDS Coordinator was solely responsible for conducting these assessments. The Assistant MDS Coordinator, who had recently begun assisting, confirmed the oversight in the tracking system that resulted in the missed assessments. The Administrator was unaware of the tracking system used by the MDS Coordinator and was not informed of any untimely assessments, although they expected assessments to be completed within the designated timeframe.
Inconsistent Tube Feeding Administration Due to Unclear Orders
Penalty
Summary
The facility failed to provide enteral nutrition per standards of practice for Resident #102, who was on a tube feeding regimen. The resident had a history of nontraumatic subarachnoid hemorrhage, type 2 diabetes mellitus, and a personal history of aneurysm rupture, which necessitated the use of a feeding tube due to poor oral intake and frequent changes in condition. The physician had ordered continuous feeding of Jevity 1.5 calorie at 30 ml per hour for 18 hours, with a 6-hour break to promote eating during the day. However, the orders were not clear, and staff did not consistently administer the tube feeding as prescribed. Observations revealed inconsistencies in the administration of the tube feeding. On several occasions, the tube feeding was either not attached or not running when it should have been, and the resident was observed not eating during meal times. Interviews with nursing staff, including RNs and LPNs, indicated confusion regarding the tube feeding schedule. Some staff believed the feeding was continuous, while others mentioned a rotating schedule without a set time for turning the feeding on and off. This inconsistency led to the tube feeding being turned off and on at varying times, not aligning with the physician's orders. The facility's policy required tube feeding to be administered by licensed nursing personnel according to physician orders, with documentation of feeding, water flush, intake, and output. However, interviews with the ADON, DON, and the facility's pharmacist highlighted a lack of familiarity with the resident's specific orders and a failure to ensure clarity in the orders. The administrator acknowledged the issue of unclear tube feeding orders, emphasizing the need for staff to seek clarification when necessary.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.14% error rate due to improper administration of levothyroxine for two residents. The errors occurred when the medication was not administered at the specified time of 6:00 A.M., before breakfast, and separate from other medications, as per physician orders. Instead, the medication was given after breakfast and alongside other medications, contrary to the instructions for it to be taken on an empty stomach. Resident #98, diagnosed with Alzheimer's disease and a thyroid disorder, was observed receiving levothyroxine at 9:05 A.M., after breakfast, and with other medications. The Registered Medication Technician (RMT) acknowledged administering the medication at the wrong time and with other medications, despite knowing it should be given at 6:00 A.M. on an empty stomach. Similarly, Resident #101, with a diagnosis of hypothyroidism, received levothyroxine at 8:57 A.M., after breakfast, and with other medications. The RMT admitted to the same error, citing the challenge of administering medications separately due to the number of residents. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed the expectation that levothyroxine should be administered before breakfast and on an empty stomach. The facility's policy allows a liberal three-hour window for medication administration, but specific instructions for certain medications, like levothyroxine, were not being followed. The DON and Administrator were aware of the issue, acknowledging that the medication timing was not in compliance with physician orders.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse/neglect policy by not reporting an allegation of inappropriate touching between two residents to the State Survey Agency within the required two-hour timeframe. The incident involved Resident #1, who was cognitively intact and had a history of bipolar disorder, Parkinson's disease, and dementia, and Resident #2, who had moderate cognitive impairment and a history of major depressive disorder and stroke. The incident was documented in nursing notes, but there was no record of the facility reporting the allegation to the Department of Health and Senior Services (DHSS). Interviews with staff revealed a lack of clarity and consistency in understanding the reporting requirements for such incidents. Certified Nurse Assistants (CNAs) and Licensed Practical Nurses (LPNs) expressed differing views on whether the incident constituted abuse and whether it needed to be reported to the state agency. Some staff believed that the guardian's or Durable Power of Attorney's (DPOA) decisions regarding residents' sexual activity should guide their actions, while others recognized the need to report the incident as potential abuse. The Director of Nursing (DON) and the Administrator also provided conflicting statements regarding the necessity of reporting the incident to the state agency. The DON did not consider the incident as needing to be reported, citing the absence of an abuse allegation, while the Administrator acknowledged the need to separate the residents and notify the guardians but did not ensure the incident was reported to the state agency. This inconsistency in policy implementation and understanding among staff and management contributed to the facility's failure to report the incident as required.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse/neglect policy effectively, as evidenced by the lack of a documented investigation into an incident involving inappropriate touching between two residents. The incident occurred when one resident was found touching another resident's genitalia in the courtyard. Despite the facility's policy requiring immediate investigation and documentation of such allegations, no written investigation was completed, and the Department of Health and Senior Services (DHSS) did not receive any report of the incident. Resident #1, who was cognitively intact and had a guardian, was involved in the incident. The resident had a history of bipolar disorder, Parkinson's disease, and dementia. The nursing notes indicated that the resident was educated about the inappropriateness of their actions, and both residents were placed on 15-minute checks. However, the facility did not conduct a formal investigation or document the incident as required by their policy. Resident #2, who had a Durable Power of Attorney (DPOA) and a history of major depressive disorder and stroke, was the other party involved. The resident expressed that such an incident would be considered traumatic. Despite this, the facility did not verify consent from Resident #2 or conduct a thorough investigation. Interviews with staff revealed a lack of clarity on handling such situations, and the facility's management did not follow through with the necessary steps to ensure compliance with their abuse/neglect policy.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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