Fulton Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fulton, Missouri.
- Location
- 520 Manor Drive, Fulton, Missouri 65251
- CMS Provider Number
- 265760
- Inspections on file
- 17
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Fulton Manor Care Center during CMS and state inspections, most recent first.
Facility staff did not complete required Criminal Background Checks (CBCs) for three CNAs before they began working with residents, despite policies requiring background and criminal conviction checks for all direct-access employees. Review of personnel files showed no documentation that CBCs were requested or obtained for these CNAs. The administrator reported relying on verification through the Family Care Safety Registry (FCSR) and, when not registered, on requests to an external association for background checks, and acknowledged not requesting CBCs from the state highway patrol since assuming responsibility for this process.
A resident with severe cognitive impairment and psychiatric diagnoses was improperly restrained in a wheelchair by a CNA who tied a sheet around the resident’s upper body and secured it to the back of the chair to control the resident’s behavior, contrary to the care plan that called for assisted ambulation, safety devices, and simple instructions without restraints. Another CNA witnessed the tying and tightening of the sheet and reported it to an LPN, who found the resident in the dining area with a blanket draped over the chair that concealed the sheet and required several minutes to untie. The CNA later admitted the restraint was used to "teach a lesson" and to prevent the resident from getting up, despite prior training on abuse and neglect.
Facility staff did not prevent the employment of a CNA who had a federal indicator for misconduct on the CNA Registry. Despite policies requiring background checks and registry reviews, the responsible staff member overlooked the federal marker and the administrator was unaware of the issue, resulting in the CNA being hired.
Facility staff failed to ensure call lights were within reach for several residents, leading to unmet needs for assistance. Observations showed residents with cognitive impairments and assistance needs were unable to access call lights, resulting in them calling out for help. Staff interviews revealed a lack of awareness and communication regarding the accessibility of call lights, with some staff acknowledging the issue of short call light strings.
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers or therapeutic leaves. This issue affected four residents, and the facility lacked a bed hold policy. Interviews revealed that the DON and administrator were unaware of the bed hold requirements and processes.
The facility failed to complete baseline care plans within 48 hours for several residents, as required by policy. The Care Plan Coordinator and DON were unclear about the timeframe, leading to delays. The administrator incorrectly stated that care plans should be completed within seven days, contributing to the deficiency.
Facility staff failed to follow professional standards by not obtaining physician's orders for water flushes during G-tube medication administration for a resident. Medications were administered without necessary water flushes, and Levothyroxine was not given separately as required. Unauthorized documentation by CMTs on the MAR was also noted, with a lack of oversight due to the absence of a DON.
Facility staff failed to meet basic hygiene needs for four residents, as observations and interviews revealed inconsistent shower offers and documentation. A resident with mild cognitive impairment was observed with greasy hair despite documented showers, while another cognitively intact resident reported not having a shower in weeks. A newly admitted resident had no documented showers, and staff interviews indicated a lack of consistent care due to a temporary absence of a DON.
The facility failed to obtain signed consents and conduct necessary side rail assessments for four residents, as required by policy. Observations showed residents with bed rails in the upright position without proper documentation. Interviews with staff revealed confusion about responsibilities, leading to non-compliance with procedures.
The facility failed to provide adequate staffing as per their Facility Assessment, resulting in unmet hygiene needs for several residents. Observations and interviews revealed that residents were not receiving regular showers or personal hygiene assistance due to understaffing. The facility's reliance on fire code regulations instead of the Facility Assessment for staffing contributed to this deficiency.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, from July 2024 to January 2025. The RN staff schedule showed numerous days without adequate RN presence, and interviews with the DON and administrator revealed a lack of awareness of the regulatory requirements. Despite recognizing the importance of RN expertise, the facility did not ensure compliance with staffing regulations.
The facility failed to post required nurse staffing information, including the facility census and actual hours worked by licensed and unlicensed staff, in an accessible location. Observations and interviews revealed that the Director of Nursing and the administrator were unaware of the missing information, despite policy requirements. The responsibility for completing the daily staffing sheet was assigned to the charge nurses, but the deficiency persisted.
A resident in an LTC facility experienced a medication administration error, resulting in a 28.13% error rate. The LPN administered multiple medications via G-tube over two hours late, contrary to the facility's policy of administering within one hour of the prescribed time. The resident expressed concern about the delay, and the LPN admitted to forgetting the scheduled administration.
The facility failed to ensure proper operation of the dishwashing machine, resulting in inadequate sanitization of kitchen wares due to low temperatures and insufficient sanitizer concentration. Manual warewashing also showed deficiencies, with improper sanitizer concentration and insufficient sanitization time. Additionally, the ice machine lacked a required air gap, indicating a failure to adhere to sanitation standards.
The facility failed to implement an effective QA/QAPI program, as there was no policy in place and no documentation of quarterly meetings held by department heads to discuss facility issues and resolutions. The administrator was unaware of the need for documentation, affecting a facility with a census of 43.
The facility failed to follow its policy for TB testing, administering the second PPD test too soon for several employees. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) effectively, as staff were not educated or alerted about residents requiring EBP, and PPE was not readily available. Observations showed staff did not wear gowns during high-contact care activities, and interviews revealed a lack of awareness and training on EBP. The new DON acknowledged the oversight issues, but no corrective actions were taken at the time.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for four residents. The facility's policies lacked a specific policy for Entrapment Risk Assessments, and the existing policy on the proper use of side rails was undated. Interviews with staff revealed a lack of awareness and adherence to regulations regarding bed rail safety, contributing to the deficiency in ensuring resident safety.
Facility staff failed to protect resident privacy by leaving computer screens with sensitive information open in public areas and not ensuring privacy during incontinence care. Two residents' medication information was exposed, and a resident was left visible to the parking lot during personal care. Staff interviews confirmed these actions were against facility policy.
The facility failed to complete the federally mandated MDS assessments within the required time frames for three residents. The MDS Coordinator was behind on completing assessments due to being pulled to work on the floor, and there was no system to ensure timely completion. The DON was unaware of the required time frames, contributing to the deficiency.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident on hospice care lacked hospice documentation in their care plan, another resident's use of bed rails was not documented, and a third resident with contractures had no interventions noted. Staff acknowledged these oversights, attributing them to the MDS/Care Plan Coordinator's responsibilities.
The facility failed to implement an Antibiotic Stewardship Program, lacking protocols and a system to monitor antibiotic use. The DON, new to the role, was unaware of any existing program, and the Corporate Nurse admitted that tracking and trending of antibiotic use had not been done. The administrator was unaware of the program's absence, indicating a lack of oversight.
A resident with a history of aggression grabbed another resident's arm, leading to a physical altercation. The aggressive resident was supposed to be monitored one-on-one after returning from the hospital, but was left unattended by an LPN who was not informed of the monitoring requirements. Surveillance footage showed no staff present during the incident, highlighting a failure in communication and supervision.
A CNA in a long-term care facility misappropriated $400 from a resident's checking account by cashing a check for personal use. The resident, who was moderately cognitively impaired, wrote the check after the CNA requested a loan to bail out a relative. The incident was reported over a month later, leading to an investigation and confirmation of the CNA's actions.
A facility failed to implement its abuse prevention policy when a PTA accused of inappropriate conduct was allowed to continue working with residents during an investigation. The policy requires immediate suspension and removal of alleged perpetrators, but the PTA remained unsupervised. The incident involved a cognitively intact resident with multiple diagnoses who reported feeling uncomfortable with the PTA's proximity and alleged inappropriate comments.
Failure to Complete Required Criminal Background Checks for Direct-Care Staff
Penalty
Summary
Facility staff failed to complete required Criminal Background Checks (CBCs) for three CNAs prior to their employment, contrary to Missouri DHSS requirements and the facility’s own policies. Record review showed that the Abuse, Neglect and Exploitation policy required screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, with documentation maintained as proof of screening. The Background Screening Investigations policy further required that background and criminal conviction checks, including fingerprinting as required by state law, be initiated within two days of an employment offer and completed prior to employment for all applicants with direct access to residents. Review of personnel files revealed that CNA A, CNA B, and CNA C, each hired on different dates, had no documentation that a CBC was requested or received. During an interview, the administrator stated he/she was responsible for requesting CBCs on all potential staff prior to hire and explained that he/she typically verified whether applicants were registered with the Family Care Safety Registry (FCSR). If applicants were registered with the FCSR, the administrator did not request a CBC, and if they were not, he/she sent a request to the Missouri Association of Nursing Home Administrators (MANHA) for a background check. The administrator also stated that he/she had not requested a CBC from the Missouri State Highway Patrol (MSHP) since assuming responsibility for employee CBCs in April 2025.
Resident Physically Restrained in Wheelchair with Sheet as Discipline
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when a CNA intentionally restrained the resident in a wheelchair using a sheet as a form of discipline and behavior control. The resident had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, anxiety disorder, and schizophrenia, and used a walker for ambulation. The resident’s care plan directed staff to assist with ambulation and transfers per therapy recommendations, use devices as appropriate for safety, provide clear, simple instructions, and offer re-orientation, but did not include the use of restraints. On the day of the incident, the CNA placed a sheet across the resident’s upper body, tied the sheet to the back of the wheelchair, and pushed the resident to the dining room. The CNA later admitted to tying the resident to the chair to “teach the resident a lesson” and to “trick the resident’s mind” so the resident would not keep getting up. The CNA acknowledged having received training on abuse and neglect, knowing it was not appropriate to restrain the resident, and understanding that the action constituted abuse, even though the CNA stated there was no intent to harm and the resident was not physically injured. Another CNA witnessed the first CNA tying the sheet around the resident and using a foot to tighten the sheet to the back of the wheelchair, and attempted to tell the CNA that the resident could not be restrained. This CNA reported the incident to an LPN. The LPN observed the resident in the dining room in a wheelchair with a blanket draped over the back, which concealed the sheet tied behind the chair, and it took the LPN several minutes to untie the knot. The facility’s investigation confirmed that the CNA had tied the resident to the wheelchair with a sheet and covered it with a blanket, constituting physical abuse and the use of an unauthorized restraint for discipline and staff convenience.
Failure to Screen and Prevent Employment of CNA with Federal Misconduct Indicator
Penalty
Summary
Facility staff failed to ensure that an employee with a federal indicator for misconduct on the Certified Nurse Aide (CNA) Registry was not hired or engaged to work. The facility's policies required screening of potential employees for any history of abuse, neglect, exploitation, or misappropriation of resident property, including checking the CNA Registry for federal indicators. Despite these policies, a review of one employee's personnel record showed that the individual was hired even though their CNA Registry indicated a federal marker for misconduct. Interviews revealed that the Social Service Director (SSD) was responsible for conducting background checks, including reviewing the CNA Registry. However, the SSD overlooked the section indicating the federal marker for misconduct, focusing instead on the active status of the CNA. The administrator was unaware of the federal indicator and acknowledged that no audits were being conducted to ensure compliance with hiring policies at the time.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to provide reasonable accommodations to meet the needs of residents by not ensuring that call lights were within reach for four residents. The facility's policy requires that call lights be accessible to residents at all times, but observations showed that call lights were consistently out of reach for several residents. For instance, Resident #4, who has cognitive impairment and requires moderate assistance, was observed multiple times with the call light across the room, leading the resident to yell for help. Similarly, Resident #10, with severe cognitive impairment and needing maximal assistance, was found in situations where the call light was not within reach, causing the resident to express confusion and inability to call for help. Resident #48's call light was secured to a wall light pull-cord, making it difficult for the resident to reach, despite the resident's ability to use the call light if it were accessible. Interviews with staff confirmed that the call light string was too short, and the Maintenance Director was unaware of the issue until it was brought to their attention. Resident #295 also experienced issues with the call light being out of reach due to a short string. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, revealed a lack of communication and awareness regarding the accessibility of call lights. The staff acknowledged the expectation that call lights should be within reach, but the deficiency persisted due to inadequate measures to ensure compliance with the facility's policy.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification to residents or their representatives regarding the bed hold policy during transfers to hospitals or therapeutic leaves. This deficiency was identified for four residents out of a sample of four, with the facility's census being 43. The facility's policies did not include a bed hold policy, and the medical records of the affected residents lacked documentation of notification about the bed hold policy at the time of their discharge and readmission. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness and understanding of the bed hold requirements and processes. The DON was unaware of the bed hold requirement, while the administrator acknowledged the existence of bed hold paperwork in the admission packet but was not familiar with the requirement or process for bed hold at the time of residents' transfer and discharge.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for five residents out of a sample of 16, as required by their policy. The policy, dated December 2016, mandates that a baseline care plan should be developed to meet the resident's immediate needs within 48 hours of admission. However, the electronic medical records (EMRs) for Residents #20, #43, #45, #46, and #48 did not contain documentation of a completed baseline care plan within the specified timeframe. Interviews with the Care Plan Coordinator revealed uncertainty and delays in completing these plans, with attempts to gather information extending beyond the 48-hour requirement. The Care Plan Coordinator admitted to trying to complete the baseline care plans within the first week rather than the required 48 hours. The Director of Nursing (DON) was unaware of the specific timeframe for completing baseline care plans and acknowledged that there was no system in place to ensure timely completion. The facility administrator stated that the initial nurse should initiate the care plan, and the Care Plan Coordinator should complete it within seven days, contrary to the policy. This lack of clarity and oversight contributed to the deficiency in meeting the residents' immediate needs upon admission.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of practice by not obtaining physician's orders for water flushes during medication administration via G-tube for a resident. The facility's policy required a physician's order for such procedures, but the resident's Physician's Order Sheet did not include this order. Despite this, medications were administered without the necessary water flushes, as observed on multiple occasions. Interviews with staff revealed a lack of awareness and communication regarding the need for such orders, indicating a breakdown in protocol adherence. Additionally, the facility staff did not administer medications as directed by the physician and the Medication Administration Record (MAR). Specifically, Levothyroxine, which was ordered to be given on an empty stomach and separately from other medications, was administered alongside other medications. This was contrary to the instructions on the MAR and the facility's policy, which emphasized the importance of timing and separation of medication administration to enhance therapeutic effects. Staff interviews highlighted a lack of attention to these instructions, with one LPN admitting to not following the MAR directions. Furthermore, the facility staff failed to ensure that only licensed personnel documented medication administration via G-tube. The MAR showed documentation by Certified Medication Technicians (CMTs), who were not authorized to administer medications via G-tube. Interviews with staff, including the Director of Nursing (DON) and the facility administrator, revealed a lack of monitoring and auditing of MARs, leading to unauthorized documentation. This issue was compounded by the absence of a DON for a period, resulting in lapses in oversight and adherence to physician orders.
Failure to Provide Adequate Hygiene Care
Penalty
Summary
The facility staff failed to provide adequate hygiene care for four residents, resulting in unmet basic hygiene needs. The facility's Bath, Shower/Tub Policy, dated February 2018, requires staff to promote cleanliness, document shower/bath occurrences, and notify supervisors of refusals. However, observations and interviews revealed that residents were not receiving showers as scheduled, and documentation was inconsistent or missing. For instance, Resident #24, with mild cognitive impairment, was observed with greasy hair despite documented showers, indicating a lack of adherence to the care plan. Resident #32, who is cognitively intact and requires supervision for bathing, reported not having a shower in several weeks and feeling neglected. The care plan lacked specific directions for assistance with ADLs, and the shower sheets showed infrequent showers with no recent offers. Similarly, Resident #35, also cognitively intact, was observed with greasy hair and unclean fingernails, suggesting infrequent bathing despite documented showers. The care plan did not provide clear instructions for ADL assistance, contributing to the deficiency. Resident #48, newly admitted, had no documented showers since admission, and observations showed poor hygiene, including greasy hair and food debris on teeth. The resident expressed a need for assistance with bathing, which was not provided. Interviews with staff, including CNAs and an LPN, revealed a lack of consistent shower offers and documentation, partly due to the absence of a Director of Nursing (DON) for a period. The facility administrator acknowledged the expectation for regular showers and the lapse in monitoring during the DON vacancy.
Failure to Obtain Consent and Conduct Bed Rail Assessments
Penalty
Summary
The facility failed to obtain signed consents for the use of bed rails and did not complete necessary side rail assessments for four residents. The facility's policy requires an assessment of the resident's risk from using bed rails, obtaining informed consent, and a physician's order before installation. However, these steps were not followed for Residents #3, #15, #20, and #46, as their medical records lacked signed informed consents and bed rail assessments. Resident #3, who was assessed with severe cognitive impairment and required substantial assistance with toileting and transfers, was observed with the left side rail in the upright position on multiple occasions. Similarly, Resident #15, who was cognitively intact and independent with bed mobility, was observed with bilateral side rails in the upright position over several days. Resident #20, who used side rails for bed mobility, and Resident #46 also had side rails in the upright position without the necessary consents or assessments. Interviews with facility staff, including an LPN and the Director of Nursing, revealed a lack of clarity and adherence to the facility's policy regarding bed rail assessments and consents. The staff were unsure about the responsibility for obtaining consents and completing assessments, leading to the deficiency in following the established procedures for bed rail use. The administrator acknowledged the oversight but was unsure why the assessments were not conducted quarterly as required.
Inadequate Staffing Leads to Unmet Hygiene Needs
Penalty
Summary
The facility failed to provide adequate staffing in accordance with their Facility Assessment, leading to unmet basic hygiene needs for several residents. The Facility Assessment outlined specific staffing requirements based on census numbers, but the employee schedules from August to December 2024 showed consistent understaffing across various shifts. This lack of sufficient staffing resulted in residents not receiving necessary care, such as showers and personal hygiene assistance, as documented in the observations and interviews with residents and staff. Resident #24, who was assessed with mild cognitive impairment and required partial assistance with personal hygiene, was observed with greasy hair on multiple occasions, indicating a lack of regular showers. Similarly, Resident #32, who was cognitively intact and required supervision for bathing, reported not being offered a shower for several weeks, leading to feelings of neglect. Resident #35, also cognitively intact and requiring assistance with personal hygiene, was observed with greasy hair and long, dirty fingernails, further highlighting the facility's failure to meet hygiene needs. Resident #48, who required assistance with ADLs, had not been documented as receiving a shower since admission, and was observed with greasy hair and food debris on teeth. Interviews with other residents and staff confirmed the perception of short staffing, with residents expressing dissatisfaction with the frequency of showers and staff acknowledging the lack of adequate assistance. The Director of Nursing and the administrator admitted to not following the Facility Assessment for staffing, instead relying on fire code regulations, which contributed to the deficiency in care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by their policy. The review of the facility's RN staff schedule from July 2024 to January 2025 revealed numerous instances where the facility did not have an RN on duty for the required hours. Specifically, there were multiple days each month where the facility lacked RN coverage for the mandated eight consecutive hours, indicating a consistent pattern of non-compliance with the staffing requirement. Interviews conducted with the Director of Nursing (DON) and the facility administrator highlighted a lack of awareness and understanding of the regulatory requirements for RN coverage. The DON admitted to being unsure of the regulation and acknowledged the importance of having an RN for their expertise and knowledge. Similarly, the administrator was aware of the deficiency in RN coverage and recognized the significance of having an RN present for their advanced nursing knowledge. Despite this awareness, the facility failed to ensure adequate RN staffing, leading to the identified deficiency.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility staff failed to complete the required nurse staffing information, which included the facility census and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility's policy, dated July 2016, mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care should be posted in a prominent location accessible to residents and visitors. However, reviews of the facility's daily staffing sheets from November 2024 to January 2025 showed that they did not contain the facility census or actual hours worked for licensed and non-licensed staff. Observations on multiple dates in January 2025 confirmed that the facility staff postings did not include the required information and were not readily accessible to residents and visitors. Interviews with the Director of Nursing (DON) and the administrator revealed that they were unaware of the missing information on the daily staffing sheets. Both acknowledged that the daily staff postings should include the facility census and actual hours worked and should be accessible to all residents and visitors. The responsibility for completing the daily staffing sheet was attributed to the charge nurses, specifically the night charge nurse, but the deficiency persisted due to a lack of awareness and oversight.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than five percent, resulting in a 28.13% error rate during the observation period. Out of 32 medication administration opportunities, nine errors were identified, affecting one resident. The errors were primarily due to the late administration of medications, which were given two hours and twenty minutes past the scheduled time. The facility's policy mandates that medications should be administered within one hour of their prescribed time, and any administration beyond this window is considered a medication error. The deficiency involved a resident who was supposed to receive multiple medications via a gastric tube during the morning medication pass. The medications included Levothyroxine, Midodrine, Vitamin D, Cyclobenzaprine, Eliquis, Fludrocortisone, Gabapentin, Fluoxetine, and Prenatal vitamins. The resident expressed concern about not receiving medications as scheduled, and the LPN responsible admitted to forgetting to administer them on time. The LPN acknowledged the error and the need to notify the Director of Nursing and the resident's physician, although this had not been done at the time of the interview.
Deficiencies in Dishwashing and Ice Machine Sanitation
Penalty
Summary
The facility staff failed to ensure the dishwashing machine operated according to the manufacturer's instructions, leading to inadequate sanitization of kitchen wares. Observations revealed that the dishwashing machine consistently failed to reach the required wash and rinse temperatures, with recorded temperatures as low as 90 degrees Fahrenheit for washing and 110 degrees Fahrenheit for rinsing. Additionally, the sanitizer concentration was below detection levels, as indicated by test strips that did not change color. Despite these issues, the Dietary Manager was unaware of the machine's failure to meet the necessary temperature and sanitizer concentration standards. The facility's manual warewashing process also demonstrated deficiencies. Staff were observed using a sanitizer concentration of 100 ppm, which was within the range stated by the Dietary Manager but not in accordance with the manufacturer's instructions, which required a concentration of 150-400 ppm. Furthermore, the sanitizing process was not consistently followed, with some items being removed from the sanitizer sink after only 30 seconds instead of the required one minute. The Dietary Manager admitted to not having read the sanitizer directions for use, indicating a lack of adherence to proper sanitization protocols. Additionally, the facility failed to maintain an air gap for the ice machine drain, which was directly connected to the floor drain without the necessary air gap. The maintenance director was unaware of this requirement, and the administrator confirmed that the maintenance director was responsible for the ice machine. This oversight further highlights the facility's failure to adhere to proper sanitation and safety standards, as the absence of an air gap can lead to potential contamination issues.
Lack of Effective QA/QAPI Program Documentation
Penalty
Summary
The facility staff failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program. The facility's policies did not include a policy for the QA/QAPI program. During an interview, the administrator stated that department heads meet quarterly to discuss various items within the facility, but there was no documentation available regarding these meetings, issues discussed, or resolutions made. The administrator was unaware that such information needed to be documented and maintained. The facility census at the time was 43.
Deficiencies in TB Testing and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own policy regarding the administration of the two-step purified protein derivative (PPD) skin test for tuberculosis (TB) for six employees. The policy required a second PPD test to be administered seven to 21 days after the first test if the initial result was negative. However, the second PPD tests for several employees were administered too soon, within five to six days after the first test, contrary to the policy. This discrepancy was attributed to the MDS Coordinator's misunderstanding of the policy and scheduling conflicts, as well as a lack of oversight from the Director of Nursing (DON) and the facility administrator. The facility also failed to implement its Enhanced Barrier Precautions (EBP) policy effectively. Staff were not educated or alerted about residents who required EBP, and appropriate personal protective equipment (PPE) was not placed in close proximity for residents with specific medical needs, such as feeding tubes and colostomies. Observations revealed that staff did not wear gowns when performing high-contact care activities, such as administering medications via G-tube or providing incontinence care, as required by the EBP policy. Interviews with staff indicated a lack of awareness and training regarding EBP requirements. The deficiencies in both TB testing and EBP implementation were compounded by inadequate communication and training from the facility's leadership. The new DON acknowledged the lack of oversight by the previous DON and the need for further education on EBP. The administrator also admitted that EBP precautions were not being followed and emphasized the importance of infection control. Despite these acknowledgments, the facility had not taken corrective actions to address these deficiencies at the time of the report.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for four residents. The facility's policies lacked a specific policy for Entrapment Risk Assessments, and the existing policy on the proper use of side rails was undated. The policy required regular checks to ensure bed rails and mattresses were appropriately secured and did not pose entrapment risks. However, the facility did not adhere to these guidelines, as evidenced by the absence of entrapment risk assessments and maintenance inspections in the electronic medical records of the sampled residents. Resident #3, who had severe cognitive impairment and required substantial assistance with toileting and transfers, was observed multiple times with the left side rail in the upright position without any documented entrapment risk assessment or maintenance inspection. Similarly, Resident #15, who was cognitively intact and independent with bed mobility, was observed with bilateral side rails in the upright position on several occasions, again without any documented assessments or inspections. Residents #20 and #46 also had side rails in the upright position without any documented entrapment risk assessments or maintenance inspections. Interviews with facility staff revealed a lack of awareness and adherence to regulations regarding bed rail safety. The Maintenance Director admitted to not conducting regular measurements of bed rails once installed and was unaware of any regulations requiring such measurements. The DON believed that the MDS coordinator was responsible for bed rail measurements but was not aware of specific regulations. The facility administrator was also unaware that entrapment assessments were not being conducted quarterly, as they believed was necessary. This lack of compliance with safety protocols and inadequate staff awareness contributed to the deficiency in ensuring resident safety.
Privacy Breaches in Resident Care and Information Handling
Penalty
Summary
The facility staff failed to protect the privacy and confidentiality of residents' personal and medical information. On two separate occasions, computer screens on medication carts were left open and unattended in public hallways, displaying sensitive medication information for two residents. This occurred despite the facility's policy requiring staff to lock or minimize computer screens when unattended. Interviews with staff, including the Care Plan Coordinator and an LPN, confirmed that the screens should have been secured to protect resident privacy. Additionally, during incontinence care for a resident, a CNA did not close the privacy curtain or window blinds, leaving the resident exposed to view from the parking lot. The resident expressed discomfort with the lack of privacy, and the CNA acknowledged the oversight, attributing it to nervousness. Interviews with the LPN and the Director of Nursing confirmed that staff are expected to ensure privacy by closing curtains and blinds during personal care activities.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility staff failed to complete the federally mandated Minimum Data Set (MDS) assessments within the required time frames for three residents out of a sample of six, with a total facility census of 43. The facility's policy, dated July 2017, outlines that the Assessment Coordinator or designee is responsible for ensuring timely submission of resident assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation Service (QIES) Assessment Submission and Processing (ASAP) system. However, the review of the MDS records for Residents #20, #24, and #48 revealed that the required assessments were not completed or submitted within the specified time frames as per the Resident Assessment Instrument (RAI) Manual guidelines. Interviews with the MDS Coordinator and the Director of Nursing (DON) highlighted issues contributing to the deficiency. The MDS Coordinator admitted to being behind on completing MDSs due to being frequently pulled to work on the floor, and acknowledged that there was no system in place to double-check the timely completion of MDSs. The DON, who was new to the facility, was unaware of the required time frames for MDS submissions. The administrator confirmed that the MDS Coordinator was responsible for completing the MDSs within the required time frames, while the DON was responsible for monitoring their completion. This lack of adherence to the required assessment time frames resulted in the deficiency noted by the surveyors.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #1, who was admitted on hospice care, did not have hospice services documented in their care plan, despite the facility's policy requiring such documentation. The Social Services Director and the MDS/Care Plan Coordinator acknowledged the oversight, noting that hospice directions should have been included in the resident's care plan. Resident #15, assessed as cognitively intact and independent in certain activities, had bed rails in use that were not documented in their care plan. Observations over several days confirmed the presence of bilateral U-Bars in the resident's bed, yet the MDS/Care Plan Coordinator mistakenly believed this was already included in the care plan. The absence of this information in the care plan was acknowledged as an oversight by the staff. Resident #16, with severe cognitive impairment and multiple diagnoses, had contractures in both upper and lower extremities that were not addressed in their care plan. Observations showed the resident in a broda chair with contracted hands, lacking any interventions. The MDS/Care Plan Coordinator admitted that interventions, such as placing washcloths in the resident's hands, were supposed to be documented but were not. The Director of Nursing and the facility administrator confirmed that the responsibility for these omissions lay with the MDS/Care Plan Coordinator, who was expected to update care plans regularly.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an Antibiotic Stewardship Program, which includes protocols and a system to monitor and track antibiotic use. The facility, with a census of 43, did not have a policy for antibiotic stewardship, and there was no process in place to track and trend antibiotic usage. Interviews revealed that the Director of Nursing (DON), who had been employed for only eight days, was unaware of any existing program. The Corporate Nurse admitted that the previous DON did not track and trend antibiotic use, and no one had been doing it. The administrator stated that the Infection Preventionist, who was the previous DON, was responsible for the program, but oversight was lacking, and she was unaware of the program's absence.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of physical aggression, grabbed the resident's arm. The incident involved two residents, one of whom was cognitively impaired and the other cognitively intact but with a history of aggressive behavior. The facility's policy defines abuse as the willful infliction of injury or intimidation resulting in harm, which includes resident-to-resident altercations. Resident #1, who was cognitively impaired, was involved in an altercation with Resident #2, who had a documented history of aggression and was assessed as cognitively intact. The care plan for Resident #2 included measures to reduce stimuli, monitor interactions, and intervene before agitation escalated. Despite these measures, Resident #2 was left unattended by LPN A, who was responsible for monitoring the resident one-on-one after returning from the hospital following a previous altercation. The incident occurred when Resident #1 propelled their wheelchair near Resident #2, who then grabbed Resident #1's arm. Surveillance footage showed no staff present at the time of the incident. Interviews revealed that LPN A was not informed of the need for continuous one-on-one monitoring, and there was a lack of communication among staff regarding the monitoring requirements for Resident #2. This failure to ensure proper supervision and adherence to the care plan led to the physical altercation between the residents.
Misappropriation of Resident Funds by CNA
Penalty
Summary
Facility staff failed to prevent the misappropriation of money from a resident's checking account when a Certified Nurse Assistant (CNA) cashed a check from the resident for personal use. The incident involved a resident who was assessed as moderately cognitively impaired with no behaviors. On June 22, 2024, the resident wrote a check for $400.00 to the CNA, who had asked to borrow the money to bail a relative out of jail, with the promise of repayment on the next payday. The resident kept the checkbook in their room and reported the incident to another CNA on July 27, 2024, after not being repaid. Upon discovery of the incident, the facility staff initiated an investigation and reported the misappropriation to the Department of Health and Senior Services, the local police department, and the resident's physician. The administrator conducted interviews with facility staff and residents, and it was confirmed that the CNA admitted to taking and depositing the check. The resident had also filed a grievance about the incident, and it was noted that a dental bill check had bounced around the same time the money was given to the CNA. The facility's policy on abuse, neglect, and exploitation mandates protection for residents' health, welfare, and rights, including the prevention of misappropriation of property. The policy requires immediate investigation of such allegations and reporting to the appropriate authorities. Staff are educated on these policies upon hire and annually, with additional training provided as needed. Despite these measures, the CNA involved in the incident admitted to knowing that accepting money from a resident was against policy.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention policy effectively, resulting in a deficiency related to resident safety. The policy, dated November 2017, mandates that any alleged perpetrator of abuse, neglect, or misappropriation of resident funds be immediately suspended from employment and removed from the property until the investigation is complete. However, the facility did not adhere to this policy when a Physical Therapy Assistant (PTA) accused of inappropriate conduct with a resident was allowed to continue working with other residents during the investigation. The administrator was aware of the allegation but did not suspend the PTA or ensure constant supervision as required by the policy. The incident involved a resident who was cognitively intact and had multiple diagnoses, including hypertension, end-stage renal failure, anxiety disorder, and a fracture. The resident reported feeling uncomfortable with the PTA's proximity and alleged that the PTA made inappropriate comments of a sexual nature. Despite these allegations, the PTA was observed in the facility without supervision, and the administrator admitted to not knowing if contracted staff should be treated the same as facility staff in such situations. This inaction led to a failure in protecting the resident and potentially others from further exposure to the alleged perpetrator.
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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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