Grand Manor Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 3645 Cook Ave, Saint Louis, Missouri 63113
- CMS Provider Number
- 265717
- Inspections on file
- 26
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Grand Manor Health Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of falls and returning from leave of absence (LOA) intoxicated signed out in the morning with an expected return time but did not come back for meals or evening medications. Staff on multiple shifts noted the resident’s absence, yet no Code Purple (missing resident) was initiated and no search was conducted, despite facility policies requiring contact attempts and Code Purple procedures when a resident fails to return as expected. Interviews showed staff confusion about Code Purple responsibilities and reliance on assumptions that the resident would return or was with family. The resident’s care plan did not include interventions for the known pattern of returning from LOA intoxicated. The resident remained out all night and was later found unresponsive off-site and subsequently expired at the hospital, leading surveyors to cite the facility for failing to prevent accident hazards and provide adequate supervision.
Staff failed to follow the abuse policy after a resident-to-resident altercation in a common television area where one resident struck another with a cane, causing a cut and bruise under the eye that later led the injured resident to request hospital evaluation. Nursing notes documented the incident and treatment, and the DON, ADON, physician, and families were notified, but the Administrator was not informed, no timely report was made to the state, and no formal administrative abuse investigation was conducted. Required elements such as obtaining staff and resident statements, interviewing a witnessing resident, reviewing both residents’ records, and updating care plans to reflect the altercation and any changes in needs were not completed, despite the facility’s written abuse and neglect policy mandating these actions for all suspected or alleged abuse events.
Staff did not consistently follow standardized recipes when preparing pureed meals, with some meals being prepared without measuring ingredients or referencing the required recipes. Dietary staff relied on personal experience rather than written instructions, and management confirmed that recipes were not always used as expected. This affected residents on pureed diets.
Two residents, both with schizophrenia, were involved in a physical altercation when one charged and struck the other in the arm near the nurse's station. The assaulted resident, who had moderate cognitive impairment, was assessed and found unharmed, while the aggressor exhibited further self-injurious behavior and was later transported to the hospital. Staff intervened to separate the residents and reported the incident according to the facility's abuse and neglect policy.
A resident with hemiplegia and other medical conditions did not receive ordered restorative therapy with weights after discharge from skilled therapy, despite clear care plan and physician orders. The lapse was due to staff turnover and communication failures, resulting in the resident not receiving the recommended exercises to maintain or improve range of motion.
A resident with moderate cognitive impairment and schizophrenia was left unsupervised in an unsecured area during a smoking break, resulting in the resident leaving the facility without staff knowledge. Staff did not immediately notice the absence, and the resident was found the next day after spending the night outside. The incident occurred due to a lack of adequate supervision and oversight during the smoking break.
Staff failed to administer and document medications as ordered for three residents, with multiple instances of blank entries on the MAR and no corresponding progress notes. Residents with conditions such as depression, orthopedic issues, heart failure, and kidney failure reported missed medications, and staff interviews confirmed that facility policy required documentation of all administered or missed doses. The DON and Administrator acknowledged that lack of documentation meant physician orders were not followed.
The facility did not maintain an effective pest control program, as evidenced by multiple residents reporting frequent sightings of mice in their rooms, the presence of dirty sticky traps, and confirmed observations of mice and droppings by staff. Affected residents included those with diabetes, schizophrenia, heart failure, and cognitive impairment. Housekeeping staff reported the issue to supervisors but received no new instructions, and the facility's recent upgrade to pest control services had not yet addressed the ongoing problem.
A resident with multiple chronic conditions was transferred to another facility without receiving written notice of transfer/discharge, and the State LTC Ombudsman was not notified as required. The transfer was initiated due to the resident's sex offender status, but staff did not communicate directly with the resident or provide the mandated notifications, resulting in a deficiency.
A resident with diabetes and a history of substance abuse left the facility without proper notification or supervision, resulting in missed insulin doses and a lack of timely monitoring. Staff failed to notice the resident's absence for several hours, did not complete required sign-out procedures, and did not perform regular rounds to verify the resident's location. Upon return, the resident was found with new skin issues and in an unclean state, highlighting failures in supervision and adherence to facility policies.
The facility failed to prevent negative balances in resident trust accounts, affecting six residents. Despite having a policy to manage resident trust responsibilities, several accounts showed negative balances due to the facility awaiting representative payee status. The BOM and administrator were aware of the issue.
The facility did not complete monthly reconciliations of resident trust accounts for January and April 2024, as required by their policy. The Business Office Manager and Administrator indicated that the previous owners restricted access to bank statements, complicating the reconciliation process. The new ownership began in May 2024, which may have affected access to necessary financial documents.
A facility failed to provide a SNF ABN to a resident after completing Medicare A therapy services, preventing the resident from knowing about remaining Medicare A days. The SSD issued only a Notice of Medicare Non-Coverage, and admitted to being unaware of the requirement to use both forms for residents with available Medicare A days.
A resident with Type 2 diabetes and dementia was transferred to the hospital after missing dialysis sessions, but the facility failed to notify the Ombudsman as required by policy. The resident's moderate cognitive impairment was noted, and interviews with staff confirmed the oversight.
The facility did not provide a bed hold notice to a resident or their representative when the resident was transferred to the emergency room. The resident, who was moderately cognitively impaired and had diagnoses including Type 2 diabetes mellitus and dementia, was sent out due to missing dialysis sessions. The Social Services Director confirmed the absence of a bed hold notice.
The facility failed to manage and monitor the drug regimens of two residents, leading to unnecessary psychotropic medication use. One resident was prescribed multiple antidepressants with incorrect indications and lacked monitoring for adverse effects. Another resident received antidepressants without a psychiatric diagnosis, and there was no evidence of monitoring for side effects. The facility did not adhere to its policy on psychotropic medication use, potentially compromising residents' well-being.
The facility failed to maintain complete medical records for three residents after migrating to a new EMR system, resulting in the absence of current care plans. Additionally, a medication prescription for a resident was inaccurately documented, leading to the administration of the wrong medication. These issues were confirmed by the facility's administration and nursing staff.
A resident's BiPAP mask was found uncovered on the bedside table, contrary to the facility's policy requiring it to be cleaned and stored in a bag when not in use. Despite the resident's confirmation of the lapse and staff acknowledgment of the policy, the mask was not properly stored, indicating a failure in the facility's infection prevention and control program.
A resident with HIV and PML did not receive their prescribed Biktarvy medication due to communication and procedural failures, leading to their hospitalization and eventual death. The facility failed to follow proper medication order processes, and there was inadequate documentation and communication regarding the medication's unavailability.
A resident was abused by another resident who pushed them to the floor, threw an unlit cigarette at them, and tapped their face. The mental health aide left the scene to call for a nurse, allowing further abuse to occur. The facility's failure to adhere to its abuse prevention and protection policies contributed to the deficiency.
Failure to Initiate Code Purple and Address Intoxication Risk for Resident on Outside Pass
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for supervising a resident on an outside pass and initiating a Code Purple (missing resident) when the resident did not return at the expected time. The resident, who had moderate cognitive impairment and diagnoses including diabetes, acute kidney failure, depression, and hypertension, signed out at 8:30 A.M. to smoke outside with an expected return time of 5:25. The resident did not return for dinner or evening medications, and staff noted that the resident’s breakfast and lunch were still in the room and that the resident was not present for multiple medication passes. Despite this, staff did not initiate a Code Purple or conduct a search when the resident failed to return by the expected time. The facility’s Resident Outside Pass policy required staff to attempt to contact the resident or responsible party when a resident did not return at the stated time and, if unable to contact the resident, to follow Code Purple procedures. The Elopements and Wandering Resident’s policy defined Code Purple as an elopement outside the facility and required staff to search the building and grounds, notify the Administrator or designee, contact police if the resident was not located, and notify the physician and family or legal representative. In this case, staff on the evening and night shifts were aware the resident had not returned, but interviews showed they either believed the resident had signed out with family, assumed the resident would “pop up,” or did not know they were supposed to initiate a Code Purple. The ADON, who was notified between 10:00 P.M. and 11:00 P.M. that the resident was not in the building, instructed the nurse only to document the situation and did not direct staff to initiate a Code Purple. The resident had a history of falls and of returning from leaves of absence intoxicated, including prior incidents where staff had to assist the resident from the ground outside or in the alley behind the facility. Progress notes documented falls associated with alcohol use, with staff noting the resident smelled of alcohol or was intoxicated, and staff sometimes held medications and notified the nurse when the resident was intoxicated. However, the care plan did not include interventions addressing the resident’s pattern of returning from LOA intoxicated or guidance for staff on how to manage this risk. The resident remained out of the facility all night without a Code Purple or search being initiated. According to hospital records, the resident was later found face down, unresponsive, in a puddle of water approximately two miles from the facility, with scattered abrasions, and was admitted in critical condition before expiring at the hospital. Staff interviews revealed inconsistent understanding and implementation of the facility’s policies. Some CNAs and a CMT stated they did not initially know what Code Purple meant or what to do if a resident did not return from LOA, while others stated that when a resident did not return, they were supposed to notify the nurse, administrator, DON, and family, and initiate a Code Purple with a search of the facility and surrounding neighborhood. The Administrator, who was the ADON at the time of the incident, stated that a Code Purple was to be called when a resident did not return from LOA or eloped, but believed it was not initiated in this case because the resident had stayed out overnight before and was his or her own responsible party. The facility’s failure to initiate a Code Purple and conduct a search when the resident did not return as expected, combined with the lack of care plan interventions addressing the resident’s known history of intoxication on return from LOA, led to the cited deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.
Failure to Report and Investigate Resident-to-Resident Altercation per Abuse Policy
Penalty
Summary
Facility staff failed to follow the facility’s abuse and neglect policy when a resident-to-resident altercation occurred and was not reported to Administration, preventing a thorough abuse investigation. The policy required that all allegations or suspicions of abuse, including resident-to-resident physical abuse and injuries of unknown origin, be reported immediately to the Administrator and appropriate agencies, and that an administrative investigation be completed with staff and resident statements, record review, and care plan updates. On the date of the incident, nursing documentation showed that one resident (Resident #1), who had moderate cognitive impairment, anemia, and ESRD, was sitting in a television area when another resident (Resident #2) was seen hitting him/her with a walking cane, causing a slight bruise/cut under the left eye. The area was cleansed, treated with triple antibiotic ointment, and bandaged, and the DON, ADON, and Resident #1’s family were notified. Nursing notes for Resident #2, who had no documented cognitive impairment or behaviors but carried diagnoses including anemia, CHF, HTN, and Alzheimer’s disease, documented that he/she was seen in the television area hitting another resident with a cane, after which the residents were separated and Resident #2 was taken to the nursing station. A message was left for Resident #2’s family and the DON and ADON were made aware. Two days later, Resident #1 complained of a headache, requested to go to the hospital to be evaluated following the altercation, and was transferred; the family and physician were notified, and the DON was made aware. Despite these events, neither Resident #1’s nor Resident #2’s care plans contained documentation regarding the resident-to-resident altercation. Interviews and record review showed that the facility did not initiate or complete the required administrative abuse investigation. RN A reported overhearing a commotion, hearing another resident (Resident #4, with moderate cognitive impairment) question Resident #2 about hitting Resident #1, and then observing a cut under Resident #1’s left eye; RN A separated the residents, took Resident #2 to the nursing station, and notified the DON, physician, and families, but was not asked to write a statement. Resident #4 later stated that Resident #1 had been watching television when Resident #2 approached and began hitting Resident #1 with a cane without any exchange of words; Resident #4 was not interviewed or asked for a written statement by facility staff. The DON stated she was told that Resident #2 had a fall and that the cane accidentally hit Resident #1, reviewed only Resident #1’s notes, did not review Resident #2’s notes, did not obtain statements, and did not conduct a full investigation. The Administrator reported she was not informed of the altercation, and both she and the DON acknowledged that the incident should have been reported to the Administrator and to the state agency within two hours and investigated thoroughly, as required by the facility’s abuse policy.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that standardized recipes were followed during the preparation of pureed meals for residents requiring such diets. Observations revealed that staff members prepared pureed chicken and potatoes without referencing or using the standardized recipes provided by the facility. One staff member blended diced chicken with an unspecified amount of water and a slice of bread, resulting in a mixture that was not smooth and did not match the facility's recipe, which required specific amounts of chicken, chicken base, and water. The same staff member also prepared pureed potatoes without knowing or measuring the amount of water added. Another staff member prepared pureed carrots with added bread, which was not included in the facility's standardized recipe for that dish. In some instances, recipes were not present during meal preparation, and staff relied on personal experience rather than following written instructions. Interviews with dietary staff and management confirmed that recipes were not consistently used or followed during meal preparation. The Dietary Manager acknowledged that cooks should reference recipes and was unable to locate a recipe for mashed potatoes. The Regional Dietary Manager and the Administrator both stated that recipes are available in the kitchen and are expected to be followed as written to ensure proper nutrition for residents. The facility had eight residents on pureed diets at the time of the survey, and the census was 112.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was physically assaulted by their roommate, who charged and hit them in the arm while the victim was sitting in a chair in the hallway near the nurse's station. The incident was witnessed by staff, and both residents were separated with assistance. The assaulted resident, who had moderate cognitive impairment, diagnoses including anemia, hypertension, and schizophrenia, and required partial to moderate assistance with ADLs, was assessed and found to have no injuries. The resident expressed not knowing why the attack occurred and reported feeling safe at the facility during a subsequent interview. The aggressor in the incident, who also had a diagnosis of schizophrenia and morbid obesity, was observed to have initiated the altercation by running toward and striking the other resident. After the incident, the aggressor exhibited further self-injurious behaviors, including scratching and biting their own arm, and threatened self-harm. The resident was removed from the area, monitored by staff, and eventually transported to the hospital after refusing initial treatment for minor injuries. The aggressor later stated that fear of being watched while sleeping prompted the attack, but denied wanting to harm anyone further. Staff interviews confirmed that the incident was reported and that both residents were separated following the altercation. The facility's abuse and neglect policy defines abuse to include resident-to-resident altercations and requires immediate reporting and intervention. The deficiency was identified due to the failure to protect a resident from physical abuse by another resident, as required by federal regulations.
Failure to Provide Ordered Restorative Therapy for Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when the facility failed to provide restorative therapy services as recommended for a resident with a history of hemiplegia, congestive heart failure, and high blood pressure. The resident was discharged from skilled occupational therapy with a recommendation for a Restorative Nursing Program, specifically an active range of motion (AROM) program using bilateral upper extremity weights. The care plan and physician orders specified the use of three to six pound weights for 20 repetitions, three times per session, to be performed three times weekly. However, there was no documentation that these restorative exercises were implemented, and the resident reported not receiving the therapy with weights, despite expressing a desire to participate to improve strength. Interviews with facility staff revealed a breakdown in communication and oversight following staff turnover in the restorative aide position. The restorative aide was unaware of the resident's order for weight exercises, and the Assistant Director of Nursing acknowledged that the order had been overlooked during the transition of responsibilities. The Director of Nursing and Administrator both confirmed that restorative orders are expected to be followed as written, but the lapse was attributed to recent staff changes and oversight.
Resident Elopement Due to Inadequate Supervision During Smoking Break
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, schizophrenia, anemia, and hypertension was left unsupervised in an unsecured outdoor area during a smoking break. The resident required partial to moderate assistance with activities of daily living and had no prior history of wandering or elopement. Despite the facility's policy requiring supervision of residents at risk for elopement, the resident was able to leave the premises without staff awareness or authorization. On the evening of the incident, staff members, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), a receptionist, and a Certified Nurse Aide (CNA), were involved in the resident's care and supervision. The resident was last seen participating in activities and waiting for a smoke break. The resident was given a cigarette by the receptionist and went outside to smoke with other residents and a CNA. After approximately 30 minutes, the CNA and other residents returned inside, but the resident did not. Staff did not immediately notice the resident's absence, and subsequent attempts to locate the resident were unsuccessful. The resident's absence was discovered when the CMT attempted to administer medication and could not find the resident. A search was initiated, and the facility followed its elopement protocol, including notifying the family and police. The resident was found the following morning by activity staff, having spent the night outside. The resident reported feeling "caged" and left the facility during the unsupervised smoking break. The resident sustained a minor burn on the forearm, which was self-reported as unrelated to the incident. The deficiency was due to the failure to provide adequate supervision and oversight, allowing the resident to elope from the facility.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
Staff failed to administer and document medications as ordered by physicians for three residents, resulting in a failure to meet professional standards of quality. Facility policies required that all physician orders be accurately transcribed and followed, and that medication administration be documented on the Medication Administration Record (MAR) immediately after administration. However, review of the MARs for the three residents revealed multiple instances where medications were either not documented as given or left blank, with no corresponding progress notes to explain the omissions. One resident with diagnoses including orthopedic conditions and depression had several medications, such as Duloxetine, Famotidine, and Hydroxychloroquine, that were not documented as administered on multiple dates. The resident reported issues with receiving pain medications, and there was no documentation in the progress notes regarding the missed doses. Another resident with high blood pressure, end stage renal disease, anxiety, and depression also had several medications, including Nortriptyline, Melatonin, and Amlodipine, left undocumented on the MAR for multiple days. This resident reported not receiving their Nortriptyline and was unsure about other missed medications. A third resident with heart failure and acute kidney failure had orders for Hydralazine and Isosorbide Dinitrate, with several doses not documented as administered and no progress notes explaining the omissions. Interviews with staff confirmed that the MAR should be initialed after medication administration and that any missed doses should be documented with reasons. The Director of Nursing and Administrator both stated that the facility's policies required strict adherence to these procedures, and that failure to document indicated the medication was not given as ordered.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice in multiple resident rooms. Despite having a written pest control policy and a contract with an outside pest service, residents consistently reported seeing mice in their rooms, and observations confirmed the presence of dirty sticky traps and, in one case, a dead mouse in a kitchen office trap. Video and photographic evidence submitted to the Department of Health and Senior Services showed mice in resident rooms, including three mice on a glue trap next to a resident's bed. Housekeeping staff reported seeing mouse droppings daily in resident rooms and stated that, after reporting these findings to their supervisor, they were not given any new instructions or guidance on how to address the issue. Residents affected included individuals with diagnoses such as diabetes, depression, schizophrenia, heart failure, acute kidney failure, anemia, and high blood pressure. Some residents had no cognitive impairment, while others had moderate cognitive impairment and required varying levels of assistance with activities of daily living. The Maintenance Director indicated that the facility had only recently upgraded its pest control service to include more comprehensive interior monitoring, but this change had not yet resolved the ongoing rodent problem at the time of the survey.
Failure to Notify Resident and Ombudsman Prior to Transfer/Discharge
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident, the resident's representative, and the State Long-Term Care (LTC) Ombudsman prior to a transfer/discharge. The transfer was initiated by corporate staff due to the resident's status as a sex offender, which was not permitted at the facility's location. The Administrator and Social Service Director (SSD) did not issue a written notice of transfer/discharge to the resident or notify the Ombudsman, as required by facility policy and federal regulations. The resident involved had a history of high blood pressure, diabetes, stroke, and seizure disorder, and required partial to moderate assistance with activities of daily living. The resident was cognitively intact, with no noted mood or behavioral issues, and was his/her own responsible party. Documentation showed that the SSD spoke only with the resident's family member about the transfer, who had no objections, but did not communicate directly with the resident regarding the discharge or provide written notice. The Administrator confirmed that she did not speak with the resident, did not issue a discharge notice, and did not contact the State LTC Ombudsman. The transfer was executed by arranging for the resident to be transported by taxi to another facility, accompanied by staff, with medications sent for safety and remaining belongings to follow. The facility's failure to follow its own policy and regulatory requirements regarding notification and documentation led to the deficiency.
Resident Left Facility Unnoticed, Missed Insulin Doses and Supervision
Penalty
Summary
A resident with diagnoses of diabetes and substance abuse, who was their own responsible party, left the facility without proper notification or supervision, resulting in a failure to administer scheduled insulin doses. Staff last observed the resident in their room between 1:00 P.M. and 2:00 P.M., but did not realize the resident was missing until approximately seven hours later. The resident did not sign out with the receptionist or notify nursing staff, and the required information on the Leave of Absence (LOA) form was incomplete, lacking an expected return time and staff initials. Multiple staff members, including CNAs, RNs, and the receptionist, failed to verify the resident's whereabouts during their shifts. The resident was not accounted for during routine rounds, and assumptions were made that the resident was in common areas such as the smoking area. The lack of communication and failure to follow the facility's Resident Outside Pass Policy and Elopement and Wandering Policy contributed to the delay in recognizing the resident's absence. As a result, the resident missed scheduled blood glucose monitoring and insulin administration, as documented by blank entries on the Medication Administration Record (MAR). Upon the resident's return, staff observed that the resident had developed new open areas on the thighs and a sore on the foot, which were not present prior to the absence. The resident was found in an unclean state, indicating a lack of care during the period away from the facility. Interviews with staff revealed gaps in following established protocols for resident supervision, sign-out procedures, and timely medication administration, all of which contributed to the deficiency.
Failure to Prevent Negative Balances in Resident Trust Accounts
Penalty
Summary
The facility failed to maintain a system that ensured residents' individual trust fund accounts did not go into a negative balance. This deficiency affected six residents out of a sample of eight, with the facility managing funds for 61 residents in total. The facility's Resident Trust Policy, dated February 2, 2024, outlined procedures for managing resident trust responsibilities, including preventing negative balances. However, a review of the Resident Trust Transaction History from May 1, 2024, to September 13, 2024, revealed that several residents had negative balances on their accounts. For instance, one resident had a negative balance of $456.23, while another had a negative balance that reached $5,444.00. During an interview, the Business Office Manager (BOM) acknowledged that resident trust accounts should not have negative balances and was aware of the issue. The BOM attributed the negative balances to the facility awaiting representative payee status for some residents, which would resolve the negative balances. The facility's administrator was also aware of and agreed with the BOM's explanation. Despite the policy in place, the facility did not adhere to the procedures, resulting in the cited deficiency.
Failure to Reconcile Resident Trust Accounts
Penalty
Summary
The facility failed to complete and maintain monthly account reconciliations of the resident trust accounts for two months, specifically January 2024 and April 2024. The facility's Resident Trust Policy mandates that a reconciliation of the bank statement module must be completed monthly by the facility's staff accountant, who is responsible for the facility's financials, and not by the Resident Trust Clerk. During an interview, the Business Office Manager (BOM) and the Administrator revealed that the previous owners of the facility no longer allowed access to the bank statements, which contributed to the failure in maintaining the reconciliations. The BOM mentioned that she believed she had copies of the bank statements, but the new ownership took over in May 2024, which may have impacted the access and reconciliation process.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident when he completed his Medicare A therapy services. This oversight prevented the resident from being informed about his remaining Medicare A days. The facility's policy, implemented on 01/01/24, required the use of the SNF ABN, Form CMS-10055, for Part A items and services. However, the Social Services Director (SSD) only issued a Notice of Medicare Non-Coverage, which the resident signed, indicating his last covered day was 08/23/24. The resident remained in the facility and reverted to Medicaid. The SSD admitted during an interview that he was unaware of the requirement to use both forms for residents with available Medicare A days.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a transfer for one of the residents, identified as R84, who was part of a sample of 26 residents. According to the facility's policy on Resident Transfer/Discharge, in cases of emergency or immediate discharge, copies of the transfer notice must be sent to the Ombudsman. R84, who was admitted for long-term care and had diagnoses including Type 2 diabetes mellitus and dementia, was transferred to the hospital on 06/06/24 after missing two dialysis sessions. The resident's most recent Quarterly Minimum Data Set indicated a moderate cognitive impairment with a BIMS score of 11. However, there were no documents in the electronic medical record showing that the transfer information was provided to the Ombudsman. Interviews with the Social Services Director, Administrator, and Director of Nursing confirmed that the transfer notice was not sent to the Ombudsman, and they were unaware of this oversight.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to one of the residents, identified as R84, or their responsible party when the resident was transferred to the emergency room. According to the facility's Bed Hold Policy, revised on 11/06/23, a copy of the policy should be provided to the resident or their legal representative when a resident is discharged to the hospital. R84, who was admitted for long-term care and had diagnoses including Type 2 diabetes mellitus and dementia, was moderately cognitively impaired with a BIMS score of 11. The review of the electronic medical record revealed no documentation of a bed hold form being provided when R84 was sent out on 06/06/24 due to missing two dialysis sessions. An interview with the Social Services Director confirmed that no bed hold notice was given to R84 upon hospital transfer.
Failure to Monitor and Manage Psychotropic Medications
Penalty
Summary
The facility failed to manage and monitor the drug regimens of two residents, R30 and R1, leading to unnecessary psychotropic medication use. For R30, the facility's records showed multiple antidepressant medications prescribed with incorrect indications, such as schizophrenia, and a lack of monitoring for adverse effects. Additionally, R30 was prescribed two antipsychotic medications from the same drug class without clear justification. The Director of Nursing (DON) and Clinical Pharmacist acknowledged these discrepancies, indicating a lack of clarity in medication indications and insufficient monitoring for side effects. R1's case involved the prescription of antidepressant medications without a corresponding psychiatric diagnosis. The resident's records indicated the use of mirtazapine for appetite stimulation, yet it was ordered with an indication for mood disorder. There was no evidence of monitoring for adverse effects of the antidepressant medications in R1's records. The DON confirmed the incorrect indication and the absence of side effect monitoring. The facility's policy on psychotropic medication use emphasizes the necessity of these drugs for specific conditions and the importance of monitoring the resident's response. However, the facility did not adhere to this policy, as evidenced by the lack of appropriate indications for medications and the absence of documented monitoring for adverse effects in both residents' cases. This oversight potentially compromised the residents' mental, physical, and psychosocial well-being.
Deficiencies in Medical Record Maintenance and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accessible medical records for three residents during a recertification and complaint survey. The electronic medical records (EMRs) for these residents did not contain current care plans following the facility's migration to a new EMR system. This deficiency was confirmed by the Administrator and Regional Director of Operations, who acknowledged that the transition to the new system was challenging and that they were still in the process of scanning hard copy chart data. As a result, Certified Nurse Aides were unable to access current Plans of Care to provide appropriate care and services. Additionally, the facility failed to accurately document a medication prescription for one resident. The resident's Medication Administration Record (MAR) showed discrepancies between the prescribed medication and what was administered. The Licensed Practical Nurse (LPN) was observed administering a different medication than what was documented in the EMR. The Director of Nursing (DON) admitted to entering the order incorrectly in the EMR, which led to the pharmacy dispensing the wrong medication. These deficiencies highlight issues with the facility's transition to a new EMR system and the accuracy of medication documentation. The lack of current care plans and incorrect medication orders could potentially impact the quality of care provided to the residents. The facility's policies on medical records and pharmaceutical services were not adhered to, resulting in incomplete and inaccurate documentation.
Improper Storage of BiPAP Mask
Penalty
Summary
The facility failed to ensure proper storage of a resident's BiPAP mask when not in use, as observed during a survey. The facility's policy requires that BiPAP masks be cleaned daily, dried well, and stored in a plastic bag or enclosed in machine storage when not in use. However, during observations on two separate occasions, the BiPAP mask of a resident with a diagnosis of respiratory failure, sleep apnea, and COPD was found lying uncovered on the bedside table. The resident, who had no cognitive impairment, confirmed that the staff had only covered the mask in a plastic bag once and had not done so since. Interviews with the nursing staff, including two LPNs, revealed that they were aware of the policy requiring the BiPAP mask to be stored in a bag, yet the mask was not stored properly. The LPNs acknowledged the oversight, and one of them inquired about the absence of a storage bag. The Regional Director of Operations also confirmed that the masks should be cleaned and bagged when not in use, indicating a lapse in adherence to the facility's infection prevention and control program.
Failure to Administer Critical HIV Medication
Penalty
Summary
The facility failed to provide a critical medication, Biktarvy, to a resident diagnosed with HIV and progressive multifocal leukoencephalopathy (PML) upon their admission. The resident's discharge paperwork from a previous facility included orders for Biktarvy, but the medication was not administered due to a series of communication and procedural failures. The resident was eventually discharged to the hospital in an unresponsive state and later expired, with the lack of Biktarvy being a contributing factor to their death as per the infectious disease physician's assessment. The facility's process for handling medication orders was not followed correctly. The Charge Nurse did not ensure the Biktarvy order was processed and communicated effectively. The pharmacy flagged the medication order due to its high cost and required approval from the DON or Administrator, which was not obtained. Additionally, there was a lack of documentation and follow-up regarding the medication's unavailability, and the resident's physician was not adequately informed about the delay. The resident's care plan did not include specific interventions for PML, and there was no documentation of the resident's condition worsening due to the lack of Biktarvy. Staff interviews revealed that the resident's paper chart and medication orders were not properly transferred and communicated between facilities. The facility's failure to administer the prescribed medication and properly document and communicate the issues led to a significant medication error, contributing to the resident's decline and eventual death.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse was not violated when one resident was abused by another resident. The incident occurred when Resident #7 pushed Resident #6 to the floor, threw an unlit cigarette at them, and tapped their face three times. The mental health aide who discovered the situation walked away to call for a nurse, leaving Resident #6 on the floor with Resident #7 still present, during which time Resident #7 threw the cigarette at Resident #6. The facility's policy mandates that staff must stay with the resident and immediately inform the charge nurse, which was not followed in this case. Resident #6, who has diagnoses including end-stage renal disease, heart failure, diabetes, and schizophrenia, was found on the floor with no visible injuries but reported being pushed by Resident #7. Resident #7, who has a history of polysubstance abuse and diabetes, admitted to pushing Resident #6 and throwing the cigarette. The altercation was reportedly triggered by a misunderstanding involving food delivered by Resident #7's family member, which Resident #6 shared with another resident. The police were called but did not file charges, and both residents were placed on supervised monitoring to avoid further contact. The facility's investigation revealed that Resident #7 was upset over Resident #6 locking their door and sharing food meant for Resident #7 with another resident. Despite the facility's policies on abuse prevention and protection, the staff's actions were insufficient to prevent the abuse. The mental health aide's decision to leave the scene to call for help, rather than staying with the residents as required, allowed further abuse to occur. The facility's failure to adhere to its own policies contributed to the deficiency in protecting Resident #6 from abuse.
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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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