Gregory Ridge Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 7001 Cleveland Avenue, Kansas City, Missouri 64132
- CMS Provider Number
- 265721
- Inspections on file
- 47
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Gregory Ridge Health Care Center during CMS and state inspections, most recent first.
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].
A resident with schizophrenia and paranoid personality disorder, with a documented history of agitation and difficulty with interpersonal interactions, physically assaulted two other residents on separate occasions. During a supervised smoke break, this resident cut in line, argued with another cognitively intact resident with a traumatic brain injury and mood/anxiety disorders, then repeatedly punched the resident in the face and head, knocking the resident to the floor and causing a lip laceration and forehead bruising. Days later, after an ongoing pattern of another cognitively intact resident with intellectual disability, oppositional defiant disorder, mood disorder, and autism entering the aggressor’s room for water despite being told not to, the aggressor shoulder‑checked this resident in a hallway and delivered multiple closed‑fist punches to the face, resulting in a bloody nose, facial swelling, and an ear scratch. Multiple staff and resident witnesses, as well as police reviewing video, confirmed that the aggressor initiated and continued the physical attacks, which met the facility’s own definition of physical abuse.
A cognitively intact resident with a history of stroke reported that a roommate with bipolar disorder, psychosis, and paranoid schizophrenia threw the resident’s cell phone, rendering it unusable, and cracked the screen of the resident’s iPad while also attempting to break their room window. The affected resident filed a grievance stating the facility was responsible and requested replacement or payment for the phone. Staff, including the Activities Director, CMTs, and Social Services Director, confirmed the resident’s reports and the existence of the grievance, and observation showed a shattered phone and cracked tablet. The admission inventory had listed an iPad and a Samsung Galaxy phone without existing damage, but the shattered phone observed was a different model, and the Administrator noted the resident had multiple phones and stated the facility was not responsible, leaving the grievance about damaged personal property unresolved despite the facility’s policy requiring prompt efforts to resolve resident grievances.
The facility failed to prevent resident-to-resident physical abuse during smoking breaks, allowing two separate altercations to escalate into physical assaults that caused facial injuries. In one case, two residents with significant psychiatric histories argued over smoking line order; staff did not correct the line issue, and one resident punched another in the eye after being bumped, resulting in bruising and redness. In another case, a resident without personal cigarettes became angry when another resident told a peer not to share a cigarette; despite verbal escalation, staff did not fully separate them and briefly left the smoke room doorway, during which the angry resident threw a metal ashtray across the room, striking the other resident’s face and causing swelling, bruising, and severe pain. These events occurred despite facility policies defining abuse and requiring staff intervention to manage escalating behaviors in common areas such as the smoking room.
Two separate incidents occurred in which staff failed to implement behavioral health care plans, CPI de‑escalation techniques, and required supervision during smoking breaks, leading to resident‑to‑resident altercations. In the first event, a resident with extensive psychiatric and behavioral diagnoses who was supposed to receive solo smoke breaks was allowed to line up with others; when another resident cut in front, the supervising CNA did not separate them or redirect either resident, and a physical fight ensued, causing a facial bruise. In the second event, a behaviorally complex resident with schizophrenia and poor impulse control became agitated over cigarette access and a peer’s rule‑enforcing comments; despite escalating verbal aggression and refusal to leave, the CNA did not call a behavioral emergency or remain in the smoke room, and the agitated resident threw an ashtray that struck another resident’s face, resulting in bruising and swelling.
The facility failed to protect two residents from abuse when they were physically assaulted by peers on separate occasions. In one event, a cognitively impaired resident with a history of aggressive behavior struck another resident multiple times, including to the head, after a disagreement related to smoking, with the victim reporting pain, fear, and needing to call for help while a CNA observed the aggressor beating the resident’s head in the room. In a second event, a severely cognitively impaired, psychotic resident with paranoid delusions and agitation picked up a dining room chair and struck another severely cognitively impaired, psychotic resident who was seated in the dining room, causing a laceration above the eye. Facility leadership and clinical staff, including the DON and a psychiatric NP, acknowledged that the chair incident met criteria for abuse, demonstrating that residents were not kept free from resident-to-resident physical abuse as required by facility policy.
The facility failed to provide individualized, resident-centered activities to meet the psychosocial needs of two residents with serious mental illness. Facility policy required assessment of resident interests, posting of activity calendars, and daily documentation of participation, but calendars were not posted, resident preferences were not clearly identified in care plans, and attendance records were incomplete. One resident, cognitively intact with schizophrenia, anxiety, and bipolar disorder, reported boredom, wanted activities beyond coloring and BINGO and opportunities to go outside, and was sent to the ER after expressing suicidal thoughts later attributed to boredom; staff acknowledged limited activities, especially at night and on weekends, and that the resident had not been specifically asked about preferred activities. Another resident with psychosis and bipolar disorder, with a PASRR Level II requiring a structured schedule, reported there was nothing to do, preferred 1:1 rather than noisy group activities, and had minimal documented activity participation over several months, while the Activity Director stated not knowing the resident’s interests and not consistently documenting attendance.
During a period of extreme outdoor cold and HVAC failure, several resident rooms experienced temperatures below the required 71°F minimum. Staff and maintenance responses were delayed or incomplete, with temperature logs lacking proper documentation. A resident reported feeling cold and had to dress warmly, while a guardian noted that staff did not offer a room move or additional blankets. The facility lacked a comprehensive policy for climate control outages and did not notify state authorities as required.
A resident with a significant psychiatric history and prior self-harm incidents was not provided with the required one-to-one, direct line-of-sight supervision as ordered. Instead, the assigned CNA sat outside the closed room, allowing the resident to access hidden scissors and inflict a serious laceration without immediate staff intervention. The deficiency was identified when the resident later sought help from an LPN, revealing the lack of adherence to supervision protocols.
A resident with a history of behavioral challenges physically assaulted another cognitively impaired resident in a common area, resulting in visible injuries. The attack was witnessed by staff and other residents, and the facility's abuse policy defined such actions as abuse. Despite care plans addressing behavioral risks, the facility did not prevent the incident, and there was uncertainty among leadership about whether the event constituted abuse.
A resident physically assaulted another resident, causing visible injuries. Although law enforcement was notified and the aggressor was taken into custody, facility leadership did not report the incident to the State Agency, citing a lack of malicious intent and significant injury. Staff interviews revealed a misunderstanding of abuse definitions and reporting requirements, resulting in a failure to comply with mandated reporting policies.
A resident with a significant history of self-harm and multiple psychiatric diagnoses did not receive consistent behavioral health services or intensive monitoring as required. Despite repeated incidents of self-injury, staff were often unaware of the resident's history, triggers, or care needs, and the care plan was not updated to reflect new interventions. The facility failed to provide trauma-informed care, counseling, or structured support services, resulting in multiple hospitalizations for the resident.
A receptionist opened a resident's package without permission and in the resident's absence, then discussed the incident with another resident, causing embarrassment and anger. The resident was aware of the correct protocol, which was not followed, and both the DON and Administrator confirmed the receptionist had been educated on resident rights and package handling procedures.
A resident with a history of spasmodic torticollis, schizophrenia, and PTSD had a personal package opened by a newly hired receptionist without their permission or presence, contrary to facility policy. The resident, who was their own responsible party and aware of the correct process, reported the incident after the receptionist argued about the procedure. Staff interviews confirmed the protocol was not followed, and the facility's policy required that residents' mail and packages be received unopened by staff.
A resident did not receive Eliquis as ordered following hospital discharge due to the facility's failure to transcribe the physician's order into the EMR and administer the medication, despite the pharmacy delivering the medication. Staff interviews revealed inconsistent processes for handling discharge paperwork and entering new orders, resulting in a significant medication error.
Two residents with significant mental health diagnoses experienced increased agitation and behavioral incidents due to staff failing to provide timely de-escalation techniques and meet their psychosocial needs, such as facilitating phone calls to family and repairing essential items like a TV and room lighting. Delays in addressing these needs led to property destruction, disruptive behaviors, and a false allegation, despite care plans and facility policies outlining the importance of early intervention and crisis prevention.
A resident with multiple psychiatric conditions was involved in a heated altercation with a CNA over cigarettes, leading to physical aggression. Another resident intervened by attempting to restrain the agitated resident. Video footage showed the CNA kicking at the resident, although contact was unclear. The facility's investigation was incomplete, lacking key interviews, and the incident was not initially classified as abuse, indicating a failure to protect residents from abuse.
The facility failed to ensure proper infection control practices during wound care and medication administration, including the use of Enhanced Barrier Precautions (EBP) and maintaining cleanliness in the medication room. Staff did not consistently change gloves or perform hand hygiene, and there was a lack of EBP signage and PPE availability for residents with open wounds. Additionally, the facility did not provide required TB testing for five residents.
The facility failed to store food properly, leaving opened bags of rice and brown sugar exposed, and a bag of au gratin mix was found with mouse droppings. Rusty shelf racks and uncovered Styrofoam cups on chipped surfaces were noted. Staff demonstrated poor hygiene, with Cook B using a glove dropped on the floor and Dietary Aide B not washing hands after drinking. The Dietary Manager and Administrator acknowledged these issues, highlighting inadequate storage and hygiene practices.
The facility failed to maintain an effective pest control program, resulting in a significant mouse infestation affecting multiple areas and residents. Observations revealed mouse droppings in various locations, including the kitchen and resident rooms. Despite weekly visits from an exterminator, the infestation persisted, with residents and staff reporting frequent sightings of mice. The facility's administration and maintenance were aware of the situation, but the measures taken were insufficient to resolve the infestation.
The facility failed to promote resident dignity by not knocking before entering rooms, affecting three residents. Despite being in-serviced on resident rights, staff, including CNAs, CMTs, and maintenance personnel, were observed entering rooms without knocking. Residents reported feeling disrespected, highlighting a deficiency in upholding dignity and respect.
The facility failed to manage resident trust funds properly, resulting in negative balances for several residents due to withdrawals without sufficient funds. The Business Office Manager acknowledged the issue, and the facility did not provide reconciled bank statements for eight months. The Administrator noted challenges with staff turnover and internet issues, but the facility's failure to adhere to its policies led to the deficiency.
The facility failed to provide privacy for resident phone calls, with the only available phone located at the nurses' station where conversations could be overheard. Two residents, both cognitively intact and with mental health diagnoses, reported discomfort and anxiety due to the lack of privacy and phone outages. Staff confirmed the issue, noting the phone's unreliability and absence of alternative communication methods.
The facility failed to ensure residents' privacy by requiring them to open mail in front of staff, affecting all residents receiving mail. Despite the facility's policy on privacy, staff interviews confirmed this practice, which was acknowledged as inappropriate by the DON.
The facility failed to provide a safe and clean environment, with multiple residents and staff reporting issues such as mouse infestations, damaged infrastructure, and inadequate maintenance. Observations revealed mouse droppings, damaged ceiling and floor tiles, and insufficient cleaning in residents' rooms and common areas. Despite weekly pest control visits, the facility struggled to address these issues, impacting the residents' living conditions.
The facility failed to ensure timely physician visits for residents, with three residents experiencing significant gaps in care. A resident with multiple psychiatric conditions did not receive timely visits, exceeding the required 30-day interval. Another resident had no documented visits between late September and late December. A third resident faced irregular visits, with a notable gap from December to February. The facility's recent change in physician services may have contributed to these oversights.
The facility did not ensure nurse staffing information was posted in accessible areas for all residents, staff, and visitors. Staffing data was only displayed in the lobby and main floor nurse's station, not on the medical, men's, or women's units. Interviews confirmed the lack of postings, particularly in locked units where residents could not access the lobby. The Director of Nursing and Administrator acknowledged the oversight, which violated the facility's policy.
The facility failed to ensure accurate narcotic medication counts and did not follow the policy requiring two nursing staff to count narcotics at shift changes. Discrepancies were found in the narcotic records for several residents, with missing signatures and incorrect counts. Staff interviews revealed that the Controlled Drugs - Count Record was not consistently signed by a second nurse, and the DON was not informed of these issues.
The facility failed to address pharmacy recommendations and ensure appropriate medication use for several residents. A resident's Ibuprofen and Levothyroxine orders lacked necessary instructions, while another resident's Pulmicort inhaler instructions were incomplete. Additionally, a resident was prescribed Valproic Acid without a documented diagnosis. Staff interviews revealed confusion over responsibility for updating medication orders, highlighting systemic issues in medication management.
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by policy. Multiple residents were prescribed psychotropic drugs without documented attempts at GDR, and pharmacy recommendations were not addressed by physicians. Interviews revealed a lack of clarity and responsibility in processing pharmacy recommendations, with the DON identified as responsible but failing to ensure compliance.
The facility failed to properly dispose of garbage and refuse, leading to an overflowing roll-off dumpster and surrounding area with trash, equipment, and furniture. Observations showed the dumpster was full, with additional trash strewn around. Staff interviews revealed issues with dumpster size and removal, and the facility lacked a policy for proper disposal.
The facility failed to provide the required 12 hours of in-service training, including dementia care and ANE, for four CNAs. Despite having a computer-based system to track training, records showed discrepancies, with some CNAs lacking documentation of necessary training hours and topics. The DON and HR were responsible for ensuring compliance, but inconsistent documentation led to the deficiency.
A facility failed to involve a cognitively intact resident in their person-centered care planning process. The resident was not aware of care plan meetings, did not participate in setting goals, and had not seen their care plan. Staff interviews revealed that while invitations were sent to guardians, there was no documentation of invitations or care plan meetings involving the resident, contrary to facility policy.
A resident in a LTC facility was unable to purchase a tablet and headphones with funds provided by their guardian due to a lack of timely action and communication among staff. Despite the guardian sending $200 for the purchase, the items were not bought, and the funds remained in the resident's account. The Activity Director, responsible for the purchase, only visited Walmart once a month and did not have the items on the list for December. The Administrator was ultimately responsible for the purchase, but the delay was due to miscommunication and lack of coordination.
A facility failed to provide a resident with an up-to-date accounting of their trust account balance and delayed the return of funds after discharge. The resident was discharged but received a refund 31 days late, and was incorrectly charged for room and board. Staffing changes and technical issues in the business office contributed to this deficiency.
The facility failed to thoroughly investigate an altercation involving a resident with multiple psychiatric diagnoses and another resident with mental health conditions. The incident, which occurred at the nurse's station, involved a heated exchange over a cigarette box, escalating to physical aggression. The investigation lacked interviews with all involved parties and witness statements, contrary to facility policies on abuse and incident reporting.
The facility failed to notify two residents and their representatives of transfers, and did not inform the Ombudsman of a discharge. One resident was transferred without a discharge notice in their medical record, and another was sent to the hospital without a transfer notice or Ombudsman notification. Staff interviews revealed a lack of awareness and adherence to the facility's notification policy.
A facility failed to accurately assess a resident's dental status on the MDS, indicating no issues despite the resident having no natural teeth or dentures. Interviews and observations confirmed the inaccuracy, with staff acknowledging the MDS should have reflected the resident's true dental condition.
The facility failed to update a resident's care plan after a fall, despite the resident having diagnoses of difficulty in walking and unsteadiness on feet. The MDS Coordinator was responsible for updating care plans, but there was confusion among staff about the timing and process, leading to a deficiency in care planning.
A resident with multiple diagnoses, including paranoid schizophrenia and bipolar disorder, received medications late on several occasions, contrary to the facility's Medication Administration Policy. Interviews with the resident and staff confirmed that medications were frequently administered outside the prescribed time frame, impacting the resident's sleep and care routine.
A resident was discharged from the facility without a comprehensive discharge summary, including a recapitulation of their stay, medication reconciliation, and a post-discharge care plan. Interviews with staff revealed that the charge nurse was responsible for completing these summaries, but the facility policy was not followed, resulting in an incomplete discharge summary.
A resident with malignant neoplasm of the laryngeal cartilage and aphasia did not receive a recommended communication device, impacting their ability to perform activities of daily living. Despite the care plan's interventions, the facility failed to implement the Speech Language Pathology recommendation for a non-speech generating device. Staff were unaware of the recommendation, and the resident expressed a need for a communication board.
A resident with a cognitive impairment and a bothersome cyst on their face missed a dermatology appointment due to transportation issues. The Social Services Director failed to promptly reschedule the appointment and notify the resident's guardian, resulting in a delay of several months before a new appointment was made. The Director of Nursing confirmed the responsibility for rescheduling lay with the Social Services Director.
A facility failed to conduct weekly skin and wound assessments for a resident with a Stage III pressure ulcer on the left heel. Despite the resident's mild risk for pressure ulcers, documentation was inconsistent and lacked necessary details. Interviews revealed that the wound nurse was responsible for assessments, but there was no auditing to ensure compliance.
The facility failed to ensure respiratory equipment was cleaned and stored properly for two residents. Observations showed nasal cannula tubing and CPAP masks were not bagged or dated, and staff interviews revealed inconsistencies in procedures for changing and storing equipment. The DON confirmed the need for weekly changes and proper storage, indicating a lapse in policy adherence.
A resident with bipolar disorder had a low lithium level that was not reported to the physician, contrary to facility policy. The resident's lithium level was 0.4, below the normal range of 0.6 to 1.3, and there was no documentation of physician notification. Interviews revealed that the nursing staff should have reported the low level immediately, and there was no audit system to ensure communication of out-of-range lab values.
The facility failed to provide routine and emergency dental services to two residents, resulting in a deficiency. One resident had loose dentures and had not been seen by a dentist, while another had broken dentures and cavities but had not been scheduled for dental care. A third resident, who was edentulous, had not been offered dental services since admission. Staff interviews revealed a lack of awareness and communication regarding the residents' dental needs.
A resident in an LTC facility was verbally and physically abused by an LPN, resulting in a contusion and knee pain. The resident, with a history of mental health disorders, was subjected to derogatory remarks, hair-pulling, and kicking. Multiple staff witnessed the incident but did not intervene. The LPN, who lacked de-escalation training, was not supposed to be on the unit and was later detained by police. The resident expressed a desire to press charges and felt unsafe unless the LPN was removed.
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.
Failure to Prevent Resident‑to‑Resident Physical Abuse by a Psychiatrically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse between residents, specifically involving three residents with significant mental health and cognitive/behavioral histories. One resident with schizophrenia, paranoid personality disorder, restlessness, and agitation had a PASARR Level II indicating a long history of serious mental illness, psychosis, irritability, agitation, and difficulty with interpersonal interactions, and a need for structured environment, behavior plans, and crisis intervention. Another resident involved had traumatic brain injury, mild cognitive impairment, mood and anxiety disorders, and care plans addressing schizophrenia, TBI-related deficits, negative behaviors, and triggers such as people being rude, with interventions including close monitoring for anxiety, agitation, impulsivity, anger, and use of a structured environment and coping skills. A third resident had mild intellectual disability, oppositional defiant disorder, persistent mood disorder, autism spectrum disorder, and a PASARR Level II documenting a history of psychomotor agitation, verbal and physical aggression, opposition to care, and intrusive/invasive behaviors, with identified needs for 24‑hour supervision, plans to address physical aggression, boundary issues, and clear crisis procedures. In the first incident, during an evening smoke break, the resident with schizophrenia and paranoid personality disorder entered the smoke room and positioned himself/herself in line behind the resident with TBI. Believing the other resident might steal money, this resident moved in front of the TBI resident, who told him/her he/she could not cut in line. The resident with schizophrenia told the other resident not to touch him/her and then struck the TBI resident in the face, causing the resident to fall to the floor. Witnesses, including a CNA and other residents, reported that the aggressor then delivered multiple additional punches to the victim’s face and head while the victim was on the ground, with at least one witness describing the aggressor as “in another world” and clearly the aggressor. The victim sustained a busted lip, bruising and swelling to the forehead, and reported being hit multiple times in the mouth, stomach, and right ear, and was subsequently found with a visible cut on the lip and a reddened, tented right ear. The facility’s internal investigation, resident interviews, staff statements, and a police report all confirmed that the aggressor repeatedly punched the victim, constituting physical abuse as defined in the facility’s abuse policy. In the second set of events, the same resident with schizophrenia and paranoid personality disorder was involved in a separate altercation with the resident with intellectual disability, oppositional defiant disorder, mood disorder, and autism. The PASARR for this second resident documented a pattern of verbal and physical aggression, intrusiveness, and the need for a specific plan to address physical aggression and boundary issues, including how to redirect and manage crises. According to multiple statements and a police report, this resident repeatedly entered the aggressor’s room to obtain water, despite being told not to enter. On one occasion, the resident went into the room without knocking to use the bathroom sink for water and returned again for more water after being told not to come in. Later, in the hallway near the dining area, video reviewed by police showed the resident with schizophrenia shoulder‑checking the other resident and then throwing multiple closed‑fist punches to the resident’s face. Staff and resident accounts described both residents swinging and grappling, falling to the floor, and requiring several staff to physically separate them. The resident with intellectual disability sustained a bloody nose, swelling and redness to the left cheek, and an ear scratch, while the aggressor had bleeding from the outer ear. The facility’s leadership and regional nurse coordinators acknowledged that what occurred between these residents, as well as between the first pair of residents, met the definition of physical abuse under the facility’s abuse policy. Across both incidents, the residents involved had documented mental health, cognitive, and behavioral conditions, with PASARR and care plan documentation identifying needs for structured environments, close monitoring for agitation, anger, and intrusive behaviors, and specific plans for managing inappropriate and aggressive behaviors and crisis situations. Despite these identified needs and the facility’s abuse policy defining physical abuse as hitting, punching, slapping, and similar acts, the resident with schizophrenia and paranoid personality disorder was able to physically assault two different residents on separate occasions, including in a supervised setting such as the smoke room and later in a hallway near the dining area. The facility census at the time was 105 residents, and multiple staff and resident witnesses consistently described the aggressor’s actions as unprovoked or escalating quickly into repeated punches, resulting in injuries that required assessment and, in one case, hospital treatment with a dissolvable suture for a lip laceration.
Failure to Address Resident Grievance After Roommate Damaged Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to maintain personal property when another resident damaged that property and the grievance was not resolved. One resident with a history of stroke, who was cognitively intact, had an admission inventory form listing an Apple iPad and a Samsung Galaxy phone, and the iPad was documented as not cracked at admission. Another resident, admitted with bipolar disorder, psychosis, and paranoid schizophrenia and assessed as moderately cognitively intact, was involved in behavioral incidents on two consecutive days, including a Code behavioral emergency response on one of those days. On the day of the incident, the resident with mental health diagnoses threw another resident’s cell phone and broke it, then paced through the medical unit. The cognitively intact resident whose property was damaged reported that their roommate had thrown their phone at the window, along with other items, in an attempt to break the window. The resident stated that the phone became unusable and that the iPad screen was cracked, though still functional. The window in the room was later broken that evening by the same roommate. The resident filed a written grievance stating that the facility was responsible for the other resident’s actions and requested that the phone be replaced or paid for as soon as possible. Multiple staff interviews confirmed that the resident reported the broken phone and damaged tablet to staff, including the Activities Director, two Certified Medication Technicians, and the Social Services Director, who acknowledged that a grievance form had been completed. Observation showed the resident had two phones, one with a shattered screen that the resident identified as the one broken by the roommate, and an iPad with a crack across the screen. The shattered phone observed was not a Samsung Galaxy, and the Administrator stated that staff had seen the resident with multiple phones and that not all devices were listed on the inventory sheet. The Administrator also reported telling the resident that the facility was not responsible for the broken phone and indicated uncertainty about how the corporate office handled property damaged by another resident, despite the facility’s resident rights policy stating that residents have the right to voice grievances and that prompt efforts will be made to resolve them, including those involving other residents’ behavior.
Failure to Prevent Resident-to-Resident Physical Abuse During Smoking Breaks
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during smoking breaks, resulting in injuries to three residents. In the first incident, two cognitively intact residents with significant psychiatric and behavioral histories were waiting in line for the smoking room. One resident, who had a history of schizophrenia, schizoaffective disorder, psychotic disorder, personality disorder, bipolar disorder, anxiety, major depressive disorder, traumatic brain injury, and prior verbal and physical threats, was supposed to smoke before others due to prior behaviors in the smoke room. Another resident with bipolar disorder, anxiety, major depressive disorder, and dementia with behaviors walked faster and cut in front of this resident in the smoking line. The resident in line reported the line-cutting to CNA A, but no corrective action was taken to move the second resident behind the first resident. The situation escalated when the first resident bumped or nudged the second resident, and the second resident turned and punched the first resident in the left eye; the first resident then hit the second resident back. Staff accounts were inconsistent regarding who struck first and whether a kick occurred, but all accounts confirmed a physical altercation resulting in a bruise, redness, and watery left eye for the first resident. The second incident involved two other cognitively intact residents with extensive psychiatric and behavioral diagnoses, including PTSD, depression, anxiety, adjustment disorder, panic attacks, histrionic personality disorder, antisocial behavior, low intellectual functioning, mild intellectual disability, bipolar disorder, and schizoaffective disorder. During an evening smoke break, one resident, who was out of personal “white” cigarettes and refused a flavored house cigarette, secretly obtained a personal cigarette from another peer. Another resident, known to have poor impulse control and boundary issues, told the peer that sharing personal cigarettes was against the rules. This led to verbal conflict, with the resident seeking the cigarette yelling, calling the other resident names, and complaining that the other resident was bossy and a tattle tale. CNA B intervened, made the aggressive resident return the cigarette, and instructed that resident to calm down or leave the smoke room. The aggressive resident moved to the far side of the room and sat down, but continued to be upset about the other resident being in their business. Despite the escalating verbal conflict, staff did not fully separate the residents or remove the aggressive resident from the smoke room, and at one point CNA B stepped out of the smoke room doorway, leaving the residents inside without direct staff presence. While the residents were in the smoke room without staff physically present inside, the aggressive resident picked up a metal ashtray and threw it across the room, striking the other resident in the left side of the face and eye area. The injured resident reported severe pain rated 9 out of 10, and assessments documented swelling, bruising, and a small abrasion under the left eye, with subsequent documentation of bruising and puffiness to the left face and temple. The aggressive resident later admitted to being angry, having had enough of the other resident being in their business, and intentionally aiming the ashtray at the other resident’s left eye. In both incidents, the facility’s failure to effectively intervene, separate residents, and maintain adequate supervision in the smoking area allowed resident-to-resident aggression to escalate to physical abuse causing injury. In both sets of events, the residents involved had known psychiatric and behavioral conditions, including histories of aggression, poor impulse control, and multiple psychiatric admissions. The facility’s own abuse and neglect policy defined abuse as the willful infliction of injury and included resident-to-resident altercations and physical abuse such as striking or injuring a resident. The incidents described show that residents were able to engage in physical aggression—punching and throwing an ashtray—resulting in observable injuries such as bruising, swelling, redness, watery eyes, and facial pain. The Administrator and ADON acknowledged that staff did not follow facility policies and procedures for managing escalating behaviors, including not moving residents in the smoking line as planned, not calling a code green when residents began yelling, not removing an aggressive resident from the smoke room, and leaving residents in the smoke room without continuous staff monitoring, which contributed to the occurrence of physical abuse between residents.
Failure to Implement Behavioral Health Interventions and CPI in Smoking Area Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and effective use of Crisis Prevention Intervention (CPI) techniques and supervision for residents with significant psychiatric and behavioral histories, resulting in two separate resident‑to‑resident altercations. In the first incident, a resident with extensive mental health diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, traumatic brain injury, suicidal ideation, and a history of verbal and physical threats was involved in a physical altercation with another resident who had bipolar disorder, anxiety, major depressive disorder, dementia with behaviors, and a history of psychiatric treatment. Both residents were care planned for behavioral risks, including potential for physical aggression and the need for early intervention, redirection, and avoidance of confrontation. The facility’s behavioral health policy required person‑centered interventions, close monitoring for distress, and provision of services in an environment conducive to psychosocial well‑being. On the day of the first incident, residents gathered at the smoke room door for a smoke break. One resident moved in front of another in line, leading to a dispute about cutting in line. The cognitively intact resident with the extensive psychiatric history had an intervention in place, initiated several days earlier due to prior peer altercations in or around the smoke room, to receive solo smoke breaks before other residents. This intervention had not been added to the care plan and was not communicated to the CNA supervising the smoke break, who had been off work and was not informed of the change. When the resident complained that another resident had cut in line, the CNA only told the second resident to get in line and did not separate the residents, did not move the second resident behind the first, and did not remove or redirect either resident despite the known behavioral risks and CPI training. The situation escalated quickly, with one resident bumping or nudging the other, followed by both residents striking each other, resulting in a bruise under the eye of one resident and reported hitting to the head and leg of the other. The second incident involved another resident with multiple serious psychiatric diagnoses, including schizophrenia, psychotic disorder, bipolar disorder, mood disorder, developmental disability, schizoaffective disorder, and a history of multiple psychiatric admissions and emergency room visits, who was care planned for restlessness, agitation, poor judgment, poor response to redirection, and triggers such as being yelled at and not being allowed to smoke. This resident’s care plan required close observation for anxiety, early intervention before loss of control, active staff monitoring during smoke breaks, and immediate staff intervention at the first sign of peer conflict or rule disputes, with staff—not peers—responsible for enforcing smoking rules. During an evening smoke break, this resident became upset when denied a personal cigarette and when another resident, who also had extensive behavioral and psychiatric diagnoses including PTSD, depression, anxiety, antisocial behavior, mild intellectual disability, poor impulse control, and a history of psychiatric admissions, verbally intervened to tell a peer not to share cigarettes. The second resident was known to assume staff‑like roles and to tell peers what to do, which was care planned as a trigger for peer conflict. During this smoke break, the supervising CNA had already informed the agitated resident about the smoking rules and told the resident to leave if they were going to be aggressive. The resident ignored redirection and continued verbal aggression, including yelling and getting close to the other resident’s face. The CNA did not call a code green at the first sign of escalating verbal aggression and did not remain in the smoke room to provide continuous supervision; instead, at the time the ashtray was thrown, there were no staff present in the smoke room, and the CNA was in the hallway. The agitated resident then picked up an ashtray and threw it across the room, striking the other resident in the face, causing a bruise under the left eye, swelling of the left cheek and temple, and pain rated 9 out of 10. Documentation later stated that multiple de‑escalation interventions were attempted, but the facility’s own investigation noted that a behavioral emergency code should have been called earlier and that the CNA was expected to do so at the first sign of verbal aggression and refusal to leave. In both incidents, the facility failed to ensure that staff followed person‑centered behavioral care plans, provided required supervision in the smoking area, and consistently implemented CPI de‑escalation techniques to prevent resident‑to‑resident altercations.
Failure to Protect Residents From Peer-to-Peer Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse, in two separate incidents. Facility policy dated 6/12/24 states that the facility is committed to protecting residents from abuse by anyone, including other residents, and defines abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish. The policy also states the facility will identify events, patterns, and trends that may constitute abuse and investigate them thoroughly. Despite this policy, surveyors identified two sampled residents who were not kept free from abuse when they were physically struck by other residents. In the first incident, a resident with schizoaffective disorder, bipolar disorder, vascular dementia, severe cognitive impairment, and a documented history of exit-seeking and aggressive behaviors with staff and peers at a prior placement struck another resident. The aggressor resident had significant memory issues, mood swings, depression, and tended to stay away from others with slow verbal responses. The victim resident had PTSD, depression, anxiety, adjustment disorder, panic attacks, poor impulse control, poor insight and judgment, irritability, and required more supervision due to poor decision making and behaviors. According to the facility’s incident report, the aggressor resident approached staff requesting to smoke and was told it was not time; the victim resident also stated it was not time for a smoke break. As the victim resident walked away from a table outside the dining room, the aggressor resident hit the victim in the back of the head. The victim reported pain to the back of the head and forearm, stated that the aggressor hit him/her several times on the head, face, and arm, screamed for help, and tried to redirect the aggressor out of the room, expressing feeling scared around the aggressor and relief that the aggressor was gone. Additional information from staff interviews further described the first incident. A CNA reported that another resident called out and the CNA then observed the aggressor resident in the victim’s room “beating” the victim’s head while the victim was in bed and the aggressor was standing. The CNA stated that after getting the victim out of bed, the aggressor came toward them, and the CNA instructed the victim to count to three so they could back up and run out of the room to get away from the aggressor. The Administrator acknowledged that an incident of abuse occurred when the aggressor struck the victim in the back of the head. The aggressor later stated that the victim had hit him/her on the cheek, so he/she hit the victim back in the stomach while inside the smoke room. In the second incident, another resident with schizophrenia, psychosis, bipolar disorder with psychotic features, borderline personality disorder, severe cognitive impairment, mood lability, paranoid delusions, agitation, intrusiveness, and a history of medication non-compliance struck a peer with a chair. This resident had significant fixed delusional ideation, was preoccupied with being continuously raped, and exhibited labile mood, agitation, rapid pressured speech, paranoia, and internal preoccupation. The victim in this incident had schizophrenia, chronic paranoid schizoaffective disorder, alcohol dependence, polysubstance abuse, a long history of psychiatric treatment and LTC placements, legal problems associated with substance use, homicidal ideation, threatening behaviors, mood lability, agitation, depression, continual auditory and visual hallucinations (many command in nature), severe paranoia, and severe cognitive impairment. The victim required verbal direction for personal care, supervision due to disorganization, and monitoring of what the hallucinated voices were telling him/her to do. According to the progress note and incident report, the aggressor resident walked into the dining room where the victim was sitting with staff nearby and was observed pacing without clear evidence of anticipated aggression. Without provocation, the aggressor quickly picked up a dining room chair and threw or struck the victim with it. The victim raised an arm to block the chair while staff verbally directed the aggressor to stop. The victim sustained a small pin-sized scratch above the right eye with some swelling and bleeding that stopped after cleaning; later observation showed a laceration above the right eye that was well approximated with redness and swelling. At the time of surveyor observation, the victim was alert to self but unable to be interviewed, and the aggressor was displaying behaviors and could not be interviewed, with the Assistant Administrator stating it was not safe to be around the aggressor. The DON, Assistant Administrator, Regional Care Plan Coordinator, and psychiatric NP all stated that the incident in which the aggressor struck the victim with a chair met the criteria for abuse. These two events demonstrate that the facility did not ensure that residents were free from abuse by other residents, as required by its own policy and regulatory standards.
Failure to Provide Resident-Centered Activities to Meet Psychosocial Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing program of activities designed to meet residents’ interests and their physical, mental, and psychosocial well-being, as required by facility policy. The policy stated that the Life Enhancement/Activity Director would coordinate comprehensive assessments, identify residents’ likes and dislikes, post activity calendars on each unit, and ensure daily documentation of resident participation in activities. Surveyors found that activity calendars were not posted, resident-specific activity interests were not consistently identified or documented, and daily participation records were incomplete or missing. Staff interviews revealed that CNAs and nurses did not know where to find information on residents’ preferred activities and had not been educated on those preferences. For one resident with schizophrenia, anxiety, and bipolar disorder, who was documented as cognitively intact and had a legal guardian, the care plan referenced behavior problems and risk for anxiety, with instructions for staff to provide a program of activities of interest and to offer activities to prevent boredom and provide healthy outlets for energy. However, the care plan did not specify which activities the resident enjoyed. The resident had been sent to the ER after expressing suicidal and self-harm threats; the facility’s investigation documented that the resident later stated he was bored and wanted to get out of the building, and the conclusion of the investigation was that the resident was not engaged in meaningful activities. The resident reported hearing voices telling him to do something bad to himself and stated he would have liked to do something besides coloring or bingo and to do something outside the building. Multiple staff, including CNAs, an LPN, the SSD, and the Activity Director, acknowledged that there were limited activities, especially at night and on weekends, and that the resident had not been specifically asked what types of activities he would like. For another resident with psychosis and bipolar disorder, who had a legal guardian and a BIMS score indicating moderate cognitive impairment, the care plan stated that staff should offer activities to prevent boredom, ensure activities were compatible with the resident’s capabilities and interests, adapt activities as needed, and invite the resident to scheduled activities. The care plan did not identify specific activities of interest. A PASRR Level II evaluation required provision of a structured environment and a schedule of daily tasks or activities. The resident reported that there was nothing to do, that staff had never asked what activities he would like, that he preferred 1:1 activities rather than large noisy groups, and that he wanted more than bingo and more activities on weekends. Activity documentation showed the resident attended activities on only two dates over more than two months, with no documented participation after the second date. The Activity Director stated not knowing what the resident liked to do and admitted not always documenting attendance. Overall, interviews with the Activity Director, Administrator, DON, and other staff confirmed that residents were not consistently assessed for activity preferences, calendars were not consistently posted, and there were few structured activities in the evenings and on weekends, contributing to residents’ reports of boredom and lack of engagement.
Failure to Maintain Safe Room Temperatures and Notify Authorities During HVAC Outage
Penalty
Summary
The facility failed to maintain resident room temperatures within the acceptable range of 71 to 81 degrees Fahrenheit during periods of outdoor temperature extremes, specifically during a heating system failure. Documentation showed that several resident rooms had temperatures as low as 60.7 F, 62.1 F, and 63.6 F over multiple days, with temperature logs often lacking signatures, dates, or clear identification of responsible staff. The deficiency was further compounded by the lack of a comprehensive, facility-specific policy and procedure for climate control system outages, and the absence of clear guidance on when to notify state agencies or the Department of Health and Senior Services (DHSS) disaster line in the event of such failures. Interviews with staff and residents revealed that the heating issues began when a resident reported a malfunctioning unit via a QR code maintenance request. The Maintenance Director responded by contacting a heating company, but repairs were delayed due to unavailable parts. Additional rooms were later found to have similar heating issues, and staff began taking hourly temperature logs. Residents reported feeling cold, with one resident stating they had to cover up and dress warmly, and another's guardian expressing concern that staff did not offer to move the resident or provide additional blankets and warm clothing. The facility's emergency disaster manual referenced maintaining interior temperatures above 71 F and outlined steps for offering blankets or room moves in emergencies, but did not specify when to notify state authorities or provide a clear process for handling HVAC outages. The Administrator acknowledged the lack of a policy for contacting the disaster line and was unaware that multiple individual unit failures required state notification. These deficiencies had the potential to affect all residents, staff, and visitors in the facility.
Failure to Provide Ordered One-to-One Supervision for Resident with History of Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to provide ordered one-to-one supervision in direct line of sight for a resident with a known history of self-harm. The resident, who had multiple psychiatric diagnoses including schizophrenia, bipolar disorder, borderline personality disorder, and a documented history of self-injury and suicide attempts, was placed on one-to-one monitoring per physician order and care plan. The care plan specified that staff were to supervise the resident at all times, especially when the resident had access to sharp objects, and to never leave the resident alone with such items. Despite these orders and the facility's policy requiring one-to-one supervision within eyesight, the assigned CNA sat outside the resident's room with the door closed during the night shift. The CNA reported being told by an unknown staff member that it was acceptable to sit outside the room and keep the door closed, and was unaware of the requirement to remain inside the room with the resident. During this period, the resident accessed a pair of small scissors hidden in a birthday gift and used them to inflict a 7 cm by 3 cm laceration on their left forearm. The incident was not immediately detected by staff, as the resident did not communicate their distress or the act of self-harm to the staff member assigned to monitor them. The failure to maintain direct line-of-sight supervision allowed the resident to self-harm without intervention. The incident was discovered only after the resident sought help from an LPN for a PRN medication, at which point the injury was noticed. Interviews with staff and the resident confirmed that the required supervision protocols were not followed, and that the resident was left unsupervised with the door closed, contrary to facility policy and physician orders.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident physically assaulted another in a common area. The incident occurred when a resident with a history of disorganized schizophrenia, major depressive disorder, and substance abuse approached another resident from behind and struck them in the head and neck, knocking them to the floor, and then proceeded to kick and stomp on the resident's head and body multiple times. The assaulted resident sustained bruising on the forehead, minor swelling on the back of the head and neck, and a small scratch on the left cheek. Multiple staff and resident witnesses confirmed the violent nature of the attack, and the assaulted resident urinated on themselves during the incident. Both residents involved had significant psychiatric histories, including schizophrenia and anxiety disorders. The resident who committed the assault was documented as cognitively intact on the most recent assessment and had a care plan indicating a history of behavioral challenges requiring protective oversight. The assaulted resident was cognitively impaired and had a care plan addressing anxiety and behavioral symptoms, with interventions to monitor and de-escalate anxiety-related behaviors. Despite these documented risks and interventions, the facility did not prevent the physical altercation from occurring in a supervised area shortly before lunch. Interviews with staff and residents revealed that the altercation was witnessed by several individuals, including the Business Office Manager and the Activities Director, who described the attack as violent and unprovoked. The facility's abuse and neglect policy defined abuse as the willful infliction of injury or pain, including resident-to-resident altercations. However, some facility leadership expressed uncertainty about whether the incident constituted abuse, citing the aggressor's mental state and possible provocation. The police were called, and the aggressor was arrested and charged with assault. The incident was reported to the guardian of the assaulted resident and local law enforcement.
Failure to Report Resident-to-Resident Physical Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of physical abuse to the State Agency as required by regulation. On 10/27/25, one resident approached another from behind in a common area, struck the individual in the head and neck, knocked them to the floor, and proceeded to kick and stomp on their head and body multiple times. The assaulted resident sustained bruising, minor swelling, and a scratch, and was attended to by facility nurses. Law enforcement was notified, and the aggressor was taken into custody and charged with assault. The incident was documented in progress notes and a facility investigation, and the victim's guardian was later informed. Despite the severity of the incident and the physical injuries observed, the facility leadership, including the DON, Regional Director of Operations, Regional Nurse Consultant, and Administrator, did not consider the event to be abuse. Their rationale was based on their interpretation that abuse requires malicious intent or significant injury, and they believed the aggressor's mental state or possible intoxication made the behavior unpredictable rather than willful. As a result, the team decided not to report the incident to the State Agency, even though the facility's policy and the State Operations Manual require reporting of such events within 24 hours if they are deemed reportable. Interviews with facility staff and consultants revealed a consistent misunderstanding or misapplication of the definitions of abuse and reportable events. Several staff members stated that, in their view, the absence of serious injury or clear malicious intent meant the incident was not reportable. The guardian of the assaulted resident expressed concern about not being fully informed and indicated that, had they known the extent of the incident, they would have requested further medical evaluation. The facility's failure to report the incident as required constitutes the identified deficiency.
Failure to Provide Behavioral Health Services and Monitoring for Resident with Self-Harm History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a known history of self-harm, as required by federal regulations and the resident's PASRR assessment. Despite clear documentation of the resident's extensive psychiatric diagnoses—including schizophrenia, bipolar disorder, borderline personality disorder, and a history of self-harm and suicide attempts—the facility did not consistently implement recommended intensive monitoring or individualized interventions. The resident experienced multiple incidents of self-harm, such as cutting with broken glass and razor blades, hitting walls, and banging their head, resulting in injuries that required emergency medical attention. These incidents were not consistently followed by updates to the care plan or the implementation of new interventions to address the resident's triggers or supervision needs. Staff interviews revealed a lack of awareness regarding the resident's behavioral health history, triggers, and required interventions. Several staff members were unaware of the resident's history of self-harm or the need for one-to-one monitoring, and some had not reviewed the care plan or received relevant behavioral health training. The facility's own policy required intensive or one-to-one monitoring for residents at risk of self-harm, but documentation showed inconsistent application of these measures, with periods where the resident was not under required observation despite recent incidents. Additionally, the care plan was not updated after repeated self-harm events, and did not include interventions related to supervision, known triggers, or parameters for pharmacological interventions. The resident's medical record lacked evidence of trauma-informed services, positive behavioral support, counseling, or other behavioral health services as indicated in the PASRR and required by the care plan. There was no documentation of daily living skills training, structured environment, or socialization supports. The failure to provide these services and to ensure staff were knowledgeable about the resident's needs resulted in repeated self-harm incidents and multiple hospitalizations for the resident.
Failure to Honor Resident Dignity and Rights During Package Handling
Penalty
Summary
Receptionist A failed to maintain a resident's dignity by opening the resident's package without permission and in the absence of the resident, contrary to facility protocol. The resident, who was moderately cognitively intact and his/her own responsible party, was aware of the correct process for package handling, which required the Activity Director or a designated staff member to allow the resident to open the package, log the contents, and update the inventory sheet. Receptionist A opened the package, placed the contents on top of the box, and argued with the resident when confronted about the breach of protocol, claiming to have been instructed to open packages. The resident reported the incident to the Activity Director and later called the hotline to report the issue, expressing feelings of anger and embarrassment. A second resident, who was cognitively intact, witnessed the incident and confirmed that Receptionist A told him/her that the first resident had gotten him/her into trouble. This public comment further embarrassed the resident involved. Interviews with the DON and Administrator confirmed that Receptionist A had been educated on resident rights and the correct process for handling packages, and both stated that the receptionist should not have opened the package or discussed disciplinary matters with residents. Receptionist A, who had only been employed for a few weeks, denied knowledge of the protocol and denied making comments to other residents, despite evidence to the contrary.
Resident's Package Opened by Staff Without Permission
Penalty
Summary
Facility staff failed to follow policy regarding residents' rights to privacy and access to their personal mail and packages. Specifically, a resident who was their own responsible party and had a history of spasmodic torticollis, schizophrenia, and PTSD, had a personal package opened by a newly hired receptionist without the resident's permission or presence. The resident, who was moderately cognitively intact and had no negative behaviors documented, was aware of the facility's process for handling packages, which required the Activity Department to be present so that items could be logged and added to the resident's inventory sheet. The incident occurred when the resident received an alert that a package had arrived and requested the receptionist to check for it. The receptionist initially denied the package's arrival, but upon checking, returned with the package already opened and its contents exposed. The resident expressed to the receptionist that packages should not be opened without the resident present, but the receptionist argued, claiming they had been instructed to open packages. The resident subsequently reported the incident to the Activity Director. Interviews with facility staff, including the Activity Director, DON, and Administrator, confirmed that the protocol was not followed and that the receptionist had been educated on resident rights and the correct process for handling packages. The receptionist, however, stated they were unaware of the policy and opened the package for the resident, only later being informed of the correct procedure. The facility's policy clearly stated that residents' mail and packages were to be received promptly and unopened by staff, and this protocol was not adhered to in this instance.
Failure to Transcribe and Administer Ordered Anticoagulant Medication
Penalty
Summary
A significant medication error occurred when the facility failed to transcribe and administer a physician's order for Eliquis, an anti-blood clotting medication, for one resident following their hospital discharge. The resident was readmitted to the facility with a hospital discharge order for Eliquis 5 mg twice daily, but this order was not entered into the facility's electronic medical record (EMR), and the medication was not administered throughout the month. The pharmacy delivered the medication to the facility, and it was signed for by an LPN, but there was no documentation of the medication being given to the resident or of the order being entered into the system. Interviews with facility staff revealed inconsistent processes for handling hospital discharge paperwork and entering new medication orders. Nurses were expected to input orders from hospital paperwork into the EMR and follow up with the hospital or physician if paperwork was missing. However, staff reported that residents sometimes returned without necessary documentation, and there was no clear accountability for ensuring orders were entered and medications administered. The LPN who received the Eliquis could not recall to whom the medication was given, and the facility was unable to determine which staff member took the medication to the resident's unit. Further interviews with the regional nurse, physicians, and the interim DON confirmed that the discharge order for Eliquis was present in the hospital paperwork and sent to the pharmacy, but not entered into the facility's records or communicated to the appropriate staff. The resident did not experience any adverse outcomes from not receiving the medication, but the failure to transcribe and administer the ordered Eliquis represented a significant medication error as per the facility's own policies and procedures.
Failure to Provide Timely De-Escalation and Psychosocial Support for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to provide timely de-escalation techniques and meet the psychosocial needs of two residents with known mental health diagnoses. For one resident with multiple psychiatric diagnoses, including bipolar disorder, schizoaffective disorder, schizophrenia, PTSD, and borderline personality disorder, staff did not respond promptly to requests to use the phone to contact family, despite the resident's known triggers of unmet needs and waiting. The resident became increasingly agitated, resulting in the destruction of personal property and the escalation of delusional behaviors, including a false allegation of sexual assault. Interviews with staff and the resident confirmed that the unit phone had been broken for an extended period, and staff did not consistently facilitate timely access to an alternative phone, contributing to the resident's distress and behavioral escalation. Another resident with schizoaffective disorder, schizophrenia, PTSD, major depressive disorder, and other mental health conditions experienced frustration and behavioral outbursts due to delays in repairing essential items in their environment, such as a broken television and a non-functioning light in their room. The resident reported increased agitation and disruptive behaviors, including throwing objects, as a result of not being able to watch sports or read in their room for several weeks. Staff interviews confirmed that the repairs were delayed, and the resident's needs were not met in a timely manner, which contributed to the escalation of behaviors. Both residents had care plans that identified their mental health needs and triggers, but there was a lack of timely intervention and communication from staff to address their requests and prevent escalation. The facility's own policies emphasized the importance of early intervention, crisis prevention, and meeting residents' needs to avoid behavioral emergencies. However, the failure to provide prompt attention to the residents' requests and environmental needs led to increased agitation, behavioral incidents, and, in one case, a false allegation requiring extensive investigation.
Failure to Protect Resident from Abuse During Cigarette Dispute
Penalty
Summary
The facility failed to protect a resident, identified as Resident #9, from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and another resident. On the day of the incident, Resident #9, who has a history of impulse disorder, borderline intellectual functioning, schizophrenia, bipolar disorder, anxiety disorder, and PTSD, was involved in a confrontation with CNA K over cigarettes. The situation escalated when Resident #9, after being denied cigarettes, became agitated and attempted to physically attack CNA K. During the altercation, another resident, Resident #89, intervened by attempting to place Resident #9 in a chokehold. The facility's video footage, although undated and without audio, showed CNA K and Resident #9 engaging in a heated verbal exchange, with CNA K forcefully pointing at Resident #9. The charge nurse intervened by positioning themselves between the two, but the situation further escalated when Resident #9 lunged at CNA K. Resident #89 then attempted to restrain Resident #9 by the neck. The video also captured CNA K kicking at Resident #9, although it was unclear if contact was made. The facility's investigation into the incident was incomplete, lacking interviews with key witnesses and involved residents. The facility's policies on abuse and neglect, as well as resident rights, were not adequately followed, as evidenced by the staff's inappropriate interactions with Resident #9 and the failure to conduct a thorough investigation. The Director of Nursing and the Administrator acknowledged the inadequacy of the investigation and the inappropriate behavior of the staff involved. Despite the video evidence and witness statements indicating potential abuse, the facility's leadership did not initially classify the incident as such, highlighting a significant deficiency in protecting residents from abuse.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for three residents, including the use of Enhanced Barrier Precautions (EBP) and appropriate signage and availability of Personal Protective Equipment (PPE). Observations revealed that staff did not consistently change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. For instance, during wound care for a resident with multiple wounds, the LPN did not change gloves or sanitize hands between handling different wounds and touching various objects in the room. Additionally, there was a lack of EBP signage and PPE availability for residents with open wounds, which was acknowledged by the staff during interviews. The facility also failed to maintain cleanliness and hand hygiene in the medication room on the Men's Locked Unit. Observations showed that the medication room was dirty, with no hand soap or paper towels available, and staff did not perform hand hygiene during medication passes. The CMT did not have hand sanitizer on the medication cart and failed to cleanse hands before and after administering medications to residents. Interviews with staff indicated a lack of clarity on who was responsible for cleaning the medication room, and it was noted that housekeeping did not have access to the room. Furthermore, the facility did not provide Tuberculosis (TB) testing for five residents, as required by their policy. The policy mandates TB testing upon admission and readmission, but this was not conducted for the sampled residents. The Director of Nursing acknowledged the oversight and the responsibility to ensure compliance with infection prevention and control measures, including the use of EBP and maintaining a clean environment for medication administration.
Food Storage and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food in a manner that protected it from mice and other contaminants, as observed during a kitchen tour. Large, opened bags of rice and brown sugar were found under the main storage prep table without being closed or dated. Additionally, a bag of au gratin mix was found with a chewed-off corner, mouse droppings, and yellow stains, indicating a pest issue. The facility also had rusty shelf racks that were not easily cleanable, and uncovered Styrofoam cups were stored on chipped and peeling surfaces. Furthermore, a bag of breadcrumbs was left open, not sealed, and dated, with gnats present and black discolored areas on the bag. These practices were not in line with the facility's policy, which lacked specific guidelines on handwashing, glove use, and food storage. The facility's staff demonstrated poor hygiene practices, as observed with Cook B and Dietary Aide B. Cook B was seen picking up a glove from the floor and continuing to handle food without changing it. Dietary Aide B was observed handling food with gloves, removing them to drink from a personal soda bottle, and then returning to food preparation without washing hands. The Dietary Manager and Administrator acknowledged these issues, stating that handwashing should occur when transitioning from dirty to clean activities and that food should be stored in sealed containers to prevent exposure to pests. The facility had a known mouse issue, with an exterminator visiting weekly, but the storage and hygiene practices observed were inadequate to protect food from contamination.
Ineffective Pest Control Leads to Mouse Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant mouse infestation affecting multiple areas and residents. Observations revealed mouse droppings in various locations, including the front conference room, kitchen, and resident rooms. In the kitchen, food items such as a bag of au gratin mix were found chewed and contaminated with mouse droppings and stains. Large, opened bags of rice and brown sugar were improperly stored, increasing the risk of pest contamination. Interviews with staff confirmed the ongoing mouse problem, despite weekly visits from an exterminator. Residents reported seeing mice in their rooms, with droppings found along baseboards and near beds. One resident noted that their mattress was on the floor, allowing mice to get into their bed. Another resident mentioned holes under the heating unit and in the baseboards, which they believed were entry points for the mice. Despite daily housekeeping efforts, mouse droppings persisted, indicating an ineffective pest control strategy. Staff interviews highlighted the severity of the issue, with reports of mice running through the facility, including the dining room and hallways. The maintenance director acknowledged the problem, attributing it to the cold weather and proximity to a field. Although a new pest control company was engaged, the infestation continued, with sticky traps proving ineffective. The facility's administration and maintenance were aware of the situation, but the measures taken were insufficient to resolve the infestation.
Failure to Promote Resident Dignity by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to uphold the dignity and respect of three residents by not adhering to the policy of knocking before entering their rooms. Resident #66, who was moderately cognitively intact, expressed feeling disrespected as staff entered without knocking. This was observed on multiple occasions, including when a Certified Medication Technician, a Certified Nursing Assistant, and maintenance staff entered the room without knocking. Similarly, Resident #78, who was moderately cognitively impaired, reported that staff entered without knocking, which was corroborated by observations of a CNA and an Environmental Services Assistant Supervisor entering without knocking. Resident #98, who was cognitively intact, also reported that staff did not knock before entering, and this was observed when maintenance staff entered the room without knocking. Interviews with various staff members, including a CMT, CNA, LPN, and the Director of Nursing, confirmed that they were in-serviced on resident rights and were instructed to knock and wait for an answer before entering rooms. Despite this training, the observations and resident reports indicate a failure to consistently implement this practice, leading to a deficiency in promoting resident dignity and respect.
Deficient Management of Resident Trust Funds
Penalty
Summary
The facility failed to properly manage and safeguard resident trust funds, resulting in the commingling of funds and negative balances for several residents. Specifically, six residents were identified with negative balances in their trust fund accounts, indicating that the facility allowed withdrawals without sufficient funds. The facility's policy mandates that resident trust fund money be safeguarded using separate accounting principles to prevent commingling, and that a reconciliation of the bank statement, checkbook, and electronic health records module be completed monthly by the corporation's staff accountant. However, the facility did not adhere to these policies, as evidenced by the negative balances and incomplete reconciliations. The facility's Business Office Manager (BOM), who had been in the position for only a week, acknowledged that negative balances occurred because residents were allowed to withdraw cash without having sufficient funds. The BOM also noted that corporate was responsible for completing bank reconciliations and maintaining documentation, but the facility failed to provide reconciled bank statements for eight of the past twelve months. The BOM highlighted residents with low account balances to prevent future negative balances, but this practice was not in place at the time of the deficiency. Interviews with the Administrator revealed that there had been significant turnover and issues within the business office, including the resignation of the previous BOM and temporary coverage by a regional person. The facility also experienced internet issues, which led to handwritten reconciliations. Despite these challenges, the Administrator stated that the resident trust fund account was supposed to be reconciled daily to ensure accurate balances. The facility's failure to maintain proper accounting and reconciliation practices resulted in the potential for all residents with trust fund accounts to be affected by these deficiencies.
Lack of Privacy for Resident Phone Calls
Penalty
Summary
The facility failed to provide privacy for residents using the facility telephone, affecting two sampled residents out of 23. The facility's policy on resident rights mandates that residents should have reasonable access to a telephone for private calls. However, observations revealed that the only available phone was located at the nurses' station in the hallway, where other residents could overhear conversations. This lack of privacy was confirmed through interviews with residents and staff, who reported that the phone lines and internet had been down for several days, further complicating communication. Resident #19, who was cognitively intact and had multiple diagnoses including schizoaffective disorder and PTSD, expressed discomfort with the lack of privacy when using the phone. The resident reported feeling nervous as other residents could hear their conversations, and there was no alternative phone available for private use. Similarly, Resident #112, also cognitively intact and diagnosed with bipolar disorder and anxiety, reported being unable to contact family due to the phone outage and lack of privacy, which increased their anxiety. Staff interviews corroborated the residents' concerns, with a Certified Medication Technician and an LPN acknowledging the lack of privacy and the phone's unreliability. The Director of Nursing confirmed that the men's unit lacked a private phone area, and there was no alternative communication method when the phone lines were down. The women's unit had a similar issue, with the only phone available being in a non-private area, and previous attempts to provide privacy had failed due to residents damaging the phones.
Failure to Ensure Privacy in Mail Handling
Penalty
Summary
The facility failed to ensure the right to open mail privately for two residents, potentially affecting all residents who receive mail. The facility's policy on resident rights emphasizes privacy and dignity, yet residents were required to open their mail in front of staff. Resident #99, who was cognitively intact, expressed discomfort with this practice, stating a preference for opening mail privately. Similarly, another resident, also cognitively intact, expressed dissatisfaction with having to open mail in front of staff, although they would be comfortable if the mail was addressed to them in care of the facility. Interviews with various staff members, including CNAs, the Activity Director, and the Social Services Director, confirmed that residents were required to open their mail in front of staff to prevent contraband and ensure receipt. The Director of Nurses acknowledged that residents should be able to open their mail privately unless there are specific restrictions placed by a guardian. Despite this acknowledgment, the practice of requiring residents to open mail in front of staff persisted, leading to a deficiency in maintaining residents' rights to privacy.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of damaged infrastructure and pest infestations. Several residents reported seeing mice in their rooms and throughout the facility, with mouse droppings found on floors, baseboards, and even on personal items such as oxygen equipment. The presence of mice was corroborated by staff, who acknowledged the ongoing pest issue despite weekly visits from a pest control company. Additionally, the facility's maintenance and housekeeping efforts were insufficient to address these problems, as evidenced by the persistent presence of mouse droppings and damaged infrastructure. Residents reported various issues with their living conditions, including damaged ceiling and floor tiles, leaking ceilings, and inadequate window coverings. These conditions were observed in multiple rooms, with some residents experiencing leaks from the ceiling due to plumbing issues in rooms above them. The maintenance director admitted that the building's age contributed to frequent leaks and that staffing shortages hindered timely repairs and maintenance. Residents also expressed concerns about the cleanliness of their rooms, with some reporting that housekeeping did not adequately clean areas such as heating and cooling registers. The facility's failure to maintain a clean and safe environment extended to the medication room on the Men's Locked Unit, which was not kept clean, and lacked hand hygiene products for staff. The facility's inability to provide a homelike environment was further highlighted by the presence of stained and loose floor tiles, broken ceiling tiles, and inadequate lighting in residents' rooms. Despite residents and staff reporting these issues, the facility did not take effective action to resolve them, resulting in ongoing safety and hygiene concerns for the residents.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals, specifically every 30 days for the first 90 days and then at least every 60 days thereafter. This deficiency was identified for three residents out of a sample of 23, with a facility census of 111 residents. The report highlights that Resident #9, who was admitted with multiple psychiatric conditions, did not receive timely visits from their physician, with gaps exceeding the required 30-day interval. Similarly, Resident #108 experienced a significant lapse in physician visits, with no documented visits between late September and late December 2024. Resident #89 also faced irregular physician visits, with notable gaps in care, including a period from December 2023 to February 2024 without a physician visit. Additionally, Resident #107 did not have a documented physician visit upon admission and had not been seen by a physician or NP since early September 2024. These lapses in physician visits were compounded by a change in physician services in September 2024, which may have contributed to the oversight. During an interview, the Director of Nursing, who had been in the position for about two weeks, acknowledged the responsibility to ensure regular physician visits. The DON confirmed that the facility had recently changed physician services, which might have affected the scheduling and documentation of visits. The report underscores the facility's failure to adhere to regulatory requirements for physician visits, as evidenced by the documented gaps in care for the sampled residents.
Failure to Post Nurse Staffing Information in Accessible Areas
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent and readily accessible area for all residents, staff, and visitors. The facility's policy required that staffing data, including the facility name, current date, resident census, and the number of hours worked by RNs, LPNs, and CNAs, be posted daily at the beginning of each shift in a location accessible to everyone. Observations revealed that staffing information was only posted on a wipe board in the lobby and at the nurse's station on the main floor, but not on the medical, men's, or women's units. Interviews with various staff members, including CNAs, LPNs, the Staffing Coordinator, and the Director of Nursing, confirmed that staffing information was not consistently posted across all units, particularly in locked units where residents could not access the lobby without assistance. The Director of Nursing and the Administrator acknowledged that staffing information should have been accessible to all residents, including those in locked units. The Administrator stated that the Staffing Coordinator and the receptionist were responsible for updating the staffing information. However, due to the lack of postings on certain units, residents in locked areas did not have access to this information unless they left the facility. This oversight resulted in a failure to comply with the facility's policy and ensure transparency and accessibility of staffing information for all residents and visitors.
Narcotic Count Discrepancies and Policy Non-Compliance
Penalty
Summary
The facility failed to ensure accurate narcotic medication counts and did not adhere to the policy requiring two nursing staff to count narcotics at the beginning and end of each shift. The facility's Administration and Accountability Policy mandates that all controlled substances be accounted for, with two licensed nurses responsible for counting and signing off on the narcotic count at the end of each shift. However, the review of the Controlled Drugs - Count Record for the Men's Locked Unit revealed significant discrepancies. On the day shift, out of 38 opportunities, four were blank, and 30 shifts were signed by the same person without a second signature. On the night shift, 35 out of 36 opportunities were blank. Additionally, there was a discrepancy in the count of controlled substances, with four cards unaccounted for. Further review of individual patient narcotic records showed inconsistencies in medication counts for several residents. One resident's Pregabalin count was off by one capsule, while another resident's Lorazepam count was correct despite discrepancies in the recorded doses given. A third resident's Hydrocodone/Tylenol record lacked signatures, dates, or times for medication administration between specific dates. Interviews with staff revealed that the Controlled Drugs - Count Record was not consistently signed or counted by a second nursing staff member, and the Director of Nursing was not informed of these discrepancies. The Director of Nursing stated that spot checks had not revealed any issues, indicating a lack of awareness or oversight of the ongoing problems.
Failure to Address Pharmacy Recommendations and Ensure Appropriate Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications and that pharmacy recommendations were addressed in a timely manner. For Resident #9, the facility did not incorporate pharmacy recommendations into the medication orders for Ibuprofen and Levothyroxine, despite repeated monthly reminders from the pharmacy. The recommendations included administering Ibuprofen with food and ensuring Levothyroxine was taken with plenty of water on an empty stomach. These recommendations were not followed for several months, indicating a lack of timely action on pharmacy reviews. Resident #108's medication regimen also showed deficiencies. The pharmacy recommended adding instructions to rinse the mouth after using the Pulmicort inhaler and assessing the use of both Famotidine and Omeprazole for GERD. These recommendations were not implemented, and the orders remained unchanged for several months. The failure to update the medication orders as per pharmacy recommendations persisted despite multiple reminders, showing a pattern of inaction. For Resident #19, the facility did not include the instruction 'Do Not Crush' for Levothyroxine on the POS and MAR, despite pharmacy notes requesting this addition. Resident #25 was prescribed Valproic Acid without a documented diagnosis or reason for its use, which was not addressed by the facility. Interviews with staff revealed a lack of clarity on who was responsible for ensuring medication orders were updated with corresponding diagnoses and pharmacy recommendations, indicating systemic issues in medication management and communication within the facility.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of gradual dose reductions (GDR) and non-pharmacological interventions for five sampled residents. The facility's policy required that residents using psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated. However, the facility did not adhere to this policy, as demonstrated by the cases of Residents #9, #108, #66, #102, and #7, where GDRs were not attempted or documented, and pharmacy recommendations were not addressed by the physicians. Resident #9 was prescribed Divalproex for bipolar disorder, but the pharmacy's recommendation to add a 'do not crush' instruction was repeatedly ignored. Additionally, there was no documentation that the resident's physician reviewed the appropriateness of the psychotropic medication, despite multiple pharmacy recommendations. Similarly, Resident #108 was prescribed Divalproex for major depression and schizophrenia, but the pharmacy's recommendations to add 'do not crush' instructions and to follow up on previous recommendations were not addressed. Resident #102 was receiving multiple psychotropic medications, including olanzapine, quetiapine, trazadone, and buspirone, but there was no documentation of a GDR attempt, despite the pharmacist's recommendation. Resident #7 was also on several psychotropic medications, and the pharmacist recommended a GDR, but the physician did not respond, and no GDR was attempted within the last 12 months. Resident #66 was on Haloperidol, Hydroxyzine, and Divalproex, and the pharmacist requested a GDR, but the psychiatrist or physician did not respond or provide a rationale for not reducing the medications. Interviews with facility staff revealed a lack of clarity and responsibility in processing pharmacy recommendations and ensuring GDRs were completed, with the Director of Nursing (DON) being identified as responsible for these tasks but failing to ensure they were carried out effectively.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, resulting in a roll-off dumpster and surrounding area overflowing with trash, equipment, and furniture. Observations over several days revealed a roll-off dumpster that was completely full, with trash bags visible over the top and additional trash, including two toilets, two mattresses, an office chair, and wood pallets, strewn around the parking lot and nearby field. The facility did not have a policy related to this deficiency. Interviews with facility staff revealed that the roll-off dumpster was used by everyone, including non-facility personnel, and was not being emptied due to a shortage of flatbed truck drivers. The Maintenance Director had instructed staff to stop using the roll-off dumpster and had contacted the rental service to have it removed, but the issue persisted. The Administrator admitted to ordering the wrong size dumpster and was in the process of ordering a new one to manage the overflow, but no documentation of these actions was provided by the time of the survey exit.
Deficiency in CNA Training Hours and Topics
Penalty
Summary
The facility failed to provide the required 12 hours of nurse aide in-service training, including essential topics such as dementia care and Abuse, Neglect, and Exploitation (ANE), for four out of five sampled Certified Nursing Assistants (CNAs) from January 2024 through December 2024. The facility's policy mandates that each CNA receive at least 12 hours of in-service training annually, covering topics like effective communication, dementia management, ANE, and others. However, a review of training records revealed that CNA A, CNA B, CNA E, and CNA G did not receive the necessary training hours or specific training in dementia and ANE. Interviews with the CNAs and facility staff highlighted discrepancies in training documentation and tracking. CNA A and CNA B mentioned receiving training through in-services and computer-based programs, but their records did not reflect the required training hours or specific topics. CNA E's records showed no documented training hours, and CNA G had only three hours of documented training. The facility's Director of Nursing (DON) and Human Resources (HR) staff were responsible for ensuring the completion of required training, but the documentation was inconsistent, with sign-in sheets not reflecting the length of training sessions. The facility's training program relied on a computer-based system to track training hours and topics, with notifications sent to employees when training was due. Despite this system, the facility failed to ensure that all CNAs completed the mandated training hours and specific topics. Interviews with the Administrator and Regional Director of Operations confirmed that the DON and HR Director were responsible for ensuring compliance with training requirements, but the lack of proper documentation and tracking led to the deficiency.
Failure to Involve Resident in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that a resident was involved in the development and implementation of their person-centered care plan. The resident, who was cognitively intact, reported not being aware of care plan meetings, not being involved in setting goals, and not having seen their care plan. The facility's policy required that residents be the focus of control in their care planning process, which was not adhered to in this case. Interviews with staff, including the Licensed Practical Nurse (LPN), Social Service Director (SSD), and Minimum Data Set (MDS) Coordinator, revealed that while invitations were sent to guardians, there was no documentation of written or verbal invitations being provided to the resident, nor was there documentation of care plan meetings that included the resident. The SSD was responsible for coordinating care plan meetings and notifying residents, but failed to document these actions in the resident's electronic medical record. The Director of Nursing (DON) expected residents to participate in their care planning and for the interdisciplinary team to document these meetings in the clinical chart. However, the lack of documentation and involvement of the resident in the care planning process indicates a failure to adhere to the facility's policy on person-centered care, resulting in the deficiency noted in the report.
Failure to Timely Purchase Resident's Requested Items
Penalty
Summary
The facility failed to ensure a resident was able to purchase items with funds provided by their guardian in a timely manner. The resident, who was cognitively intact and had some behavioral issues, was admitted to the facility and had requested a tablet and headphones. The guardian had sent $200 to the resident's account for this purpose, but the items were not purchased. The resident's Progress Notes and Interdisciplinary Team Notes indicated the resident's request, but there was no documentation of the purchase or any communication with the guardian about withholding the purchase. Interviews revealed that the guardian was unaware of any instructions to withhold the purchase due to the resident's behavior, and the funds remained in the resident's account. The Activity Director, who was responsible for purchasing the items, only visited Walmart once a month and did not have the items on the list for the December trip. The Director of Nursing and the Administrator were also involved, with the Administrator being responsible for the purchase. The delay in purchasing the tablet and headphones was due to a lack of communication and coordination among the staff.
Failure to Timely Return Resident Trust Funds
Penalty
Summary
The facility failed to adhere to its policy regarding the timely notification and return of a resident's trust account balance upon discharge. Specifically, the facility did not provide Resident #168 with an up-to-date accounting of their trust account balance and delayed the return of the resident's funds. The resident was discharged on October 1, 2024, but the refund was not sent until November 5, 2024, which was 31 days late according to state requirements and facility policy, and five days late according to federal requirements. Additionally, the resident was incorrectly charged for room and board for October 2024, despite having been discharged at the beginning of the month. Interviews with the Business Office Manager (BOM) and the Administrator revealed a lack of continuity and oversight in the business office, contributing to the deficiency. The BOM had only been in the position for a short time and acknowledged the delay in returning the resident's funds. The Administrator noted that there had been several changes in the business office personnel, including a resignation and temporary coverage by a regional person, which led to disruptions in managing resident accounts. These staffing issues, compounded by technical difficulties with internet systems, resulted in the failure to follow the facility's policy for managing discharged residents' trust accounts.
Incomplete Investigation of Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving two residents and a staff member. The incident involved Resident #9, who has multiple psychiatric diagnoses, and Resident #89, who also has mental health conditions. The altercation occurred at the nurse's station, where Resident #9 engaged in a heated exchange with CNA K over a cigarette box. The situation escalated when Resident #9 attempted to physically attack CNA K, and Resident #89 intervened by trying to restrain Resident #9. The video footage of the incident lacked a timestamp and audio, making it difficult to ascertain the exact details of the verbal exchange. The facility's investigation into the incident was incomplete, as it did not include interviews with all involved parties, such as Resident #9, Resident #89, CNA L, and CMT E. The investigation also lacked witness statements and a Registered Nurse Incident (RNI) report. The Administrator and Director of Nursing acknowledged that the investigation was incomplete and did not meet the facility's policy requirements for abuse investigations, which should include comprehensive interviews and documentation from all witnesses and involved individuals. The facility's policies on abuse and neglect, as well as incident reporting, emphasize the importance of thorough investigations, including root cause analysis and obtaining written documentation from witnesses. However, these procedures were not followed in this case, leading to a deficiency in the facility's handling of the incident. The lack of a complete investigation raises concerns about the facility's ability to ensure protective oversight and address potential abuse situations effectively.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents and their representatives, as well as to the Ombudsman, as required by policy. For Resident #116, who was his/her own responsible party, there was no notice of discharge documented in the electronic medical record when the resident was transferred to another facility. Interviews with the Licensed Practical Nurse, Social Services Director, and Administrator confirmed that the facility policy was not followed, and the notice of discharge was not completed or uploaded into the resident's medical record. For Resident #115, who was transferred to the hospital due to severe pain, there was no transfer notice of discharge documented, nor was there any evidence that the Ombudsman had been notified of the discharge. Interviews with the Administrator, LPN, Social Services Director, and Director of Nursing revealed that the notice of transfer had not been initiated, and the Ombudsman was not informed. The staff members were unaware of these omissions, indicating a breakdown in communication and adherence to the facility's discharge notification policy.
Inaccurate Dental Assessment on MDS
Penalty
Summary
The facility failed to accurately assess a resident's dental status on the Minimum Data Set (MDS), a federally mandated assessment tool used for care planning. The deficiency was identified in one resident out of a sample of 23, within a facility census of 111 residents. The resident in question was cognitively intact and reported having no natural teeth or dentures upon admission. However, the admission MDS inaccurately indicated that the resident had no issues with their teeth. This discrepancy was confirmed through interviews and observations, which showed the resident had no natural teeth or dentures. Interviews with facility staff, including the Social Services Director, Licensed Practical Nurse, MDS Coordinator, and Director of Nursing, revealed that the MDS Coordinator was responsible for ensuring the accuracy of the MDS assessments. All staff members acknowledged that the resident's MDS should have accurately reflected the absence of natural teeth and dentures. The failure to do so was considered an inaccuracy in the MDS assessment, as confirmed by multiple staff members.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, including Resident #72, who was admitted with a diagnosis of difficulty in walking and unsteadiness on feet. Despite having no history of falls upon admission, the resident's care plan was not updated to include falls after an incident where the resident fell in their room and was sent to the hospital for evaluation and treatment. This oversight occurred despite the facility's policy requiring care plans to be updated with measurable objectives and time frames to meet residents' needs as identified in their comprehensive assessments. Interviews with facility staff, including the LPN, MDS Coordinator, Social Services Director, and Interim DON, revealed a lack of clarity and responsibility regarding the updating of care plans following a fall. The MDS Coordinator was identified as responsible for updating care plans after a fall, which is considered a change in condition. However, there was confusion about the timing and process for updating care plans, as the Interim DON was unaware of when updates should occur, although they expected updates after a fall. This lack of coordination and adherence to policy contributed to the deficiency in care planning for Resident #72.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that medications prescribed by the physician were administered within the designated time frame for one resident. The resident, who was diagnosed with paranoid schizophrenia, bipolar disorder, insomnia, and chronic pain, experienced multiple instances where medications were administered late. The medications included Buspirone Hydrochloride, Chlorpromazine, Sodium Chloride, Atorvastatin Calcium, Baclofen, Hydroxyzine, Lorazepam, Trazodone, Loratadine, and MedroxyProgesterone Acetate. These medications were given outside the one-hour window before or after the scheduled time, as per the facility's Medication Administration Policy. Additionally, some medications were administered without a corresponding diagnosis listed on the resident's face sheet. Interviews with the resident and facility staff revealed that medications were frequently administered late, sometimes hours after the scheduled time. The resident expressed difficulty sleeping due to the late administration of medications. Staff interviews confirmed that there were occasions when medications were not administered within the prescribed time frame, and the Director of Nursing acknowledged that medications were occasionally late. Furthermore, it was noted that the pharmacy's monthly checks were not effective in ensuring that the diagnosis matched the reason for the medication.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident who was discharged to another facility. The resident, who was their own responsible party, was admitted to the facility and later discharged without a recapitulation of their stay, including diagnosis, course of illness/treatment, therapy, pertinent labs, radiology, and consultation results. Additionally, there was no reconciliation of pre-discharge medications with post-discharge medications, nor was there a post-discharge plan of care developed to assist the resident in adjusting to their new living environment. Interviews with facility staff, including an LPN, the Social Services Director, the Administrator, and the Director of Nursing, revealed that the charge nurse was responsible for completing discharge summaries, which should be documented in the resident's electronic medical record. However, the discharge summary for this resident was incomplete, and the facility policy was not followed. The Director of Nursing acknowledged that all departments were responsible for ensuring discharge summaries were completed and uploaded into the resident's electronic medical record, but this was not done in this case.
Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication device for a resident diagnosed with malignant neoplasm of the laryngeal cartilage and aphasia, which affected their ability to perform activities of daily living related to communication. The resident was admitted with a communication problem, and the care plan included interventions such as allowing adequate time to respond and using alternative communication tools as needed. However, the care plan did not include the Speech Language Pathology (SLP) recommendation for a non-speech generating device, which was necessary for the resident's communication needs. Observations and interviews revealed that the resident had difficulty with speech and relied on nodding or shaking their head to communicate. Staff members, including a Certified Medication Technician and the Administrator, were unaware of the SLP's recommendation for a communication device, and no such device was found in the resident's room. The resident expressed a desire for a communication board to better express their needs. The Director of Nursing expected therapy recommendations to be implemented and was unaware that the resident did not have a communication device.
Failure to Reschedule Dermatology Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a dermatologist as required. The resident, who was moderately cognitively impaired and had a guardian, was observed with a golfball-sized cyst on the left side of their face, which was bothersome and should have been addressed months ago. An appointment with a dermatologist was initially scheduled but was canceled due to transportation issues, and the appointment was not rescheduled promptly. The resident's guardian was not informed of the canceled appointment, and a new appointment was not made until several months later. The Social Services Director (SSD) was responsible for scheduling the resident's medical appointments and ensuring transportation, but admitted to missing the rescheduling of the appointment. The SSD acknowledged that the appointment should have been rescheduled the same week as the original appointment and that the guardian should have been notified of the missed appointment. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the SSD was responsible for rescheduling missed appointments and ensuring transportation, and that the rescheduling should have occurred immediately after the cancellation.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure weekly skin and/or wound assessments were completed for a resident with a left heel Stage III pressure ulcer. The resident, who also had diabetes, was readmitted to the facility with blisters on both lower extremities and a left heel pressure ulcer. However, the documentation lacked detailed descriptions or measurements of the wounds. Despite the resident's Braden Risk Assessment indicating a mild risk for developing pressure ulcers, there was no documentation of a detailed assessment or measurements of the wounds since the resident's readmission. The resident's care plan was updated to reflect the presence of a Stage III pressure ulcer on the left heel, and the wound nurse was supposed to follow up. However, subsequent skin and wound assessments were inconsistent and lacked necessary details. For instance, a Skin Check documented a diabetic foot ulcer as a new skin issue, but the description was inconsistent with other records. Additionally, there was no documentation of skin/wound assessments on specific dates in October, November, and December, indicating a failure to conduct regular assessments. Interviews with staff revealed that the wound nurse was responsible for weekly assessments, but there was no auditing to ensure compliance. The Director of Nursing acknowledged the expectation for weekly assessments and documentation but admitted to not auditing the process. This lack of consistent documentation and assessment highlights a deficiency in the facility's wound care management for the resident.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary condition for two residents, leading to deficiencies in care. Resident #72, who was admitted with a diagnosis of obstructive sleep apnea, had orders for oxygen therapy and CPAP use. However, observations revealed that the nasal cannula tubing was not stored in a sanitary manner, as it was not bagged or dated and was wrapped around a portable oxygen tank. Additionally, the CPAP mask was found on the floor and not in a bag. The resident reported that the nasal cannula tubing was never cleaned or changed by staff, and the CPAP mask was found covered in mice droppings, indicating a lack of proper maintenance and storage. Resident #27, who did not have a respiratory-related diagnosis on record, was observed using oxygen therapy at 2 liters per minute via nasal cannula. Similar to Resident #72, the nasal cannula tubing was not dated or stored properly when not in use. The resident stated that they had never seen staff clean or change the nasal cannula tubing, and it was never covered when not in use. Observations confirmed that the tubing was left on the bed and not bagged, with the oxygen tank running continuously. Interviews with facility staff, including a CMT, LPN, CNA, and the DON, revealed inconsistencies and a lack of clarity regarding the procedures for changing and storing respiratory equipment. Staff members were unsure of the exact frequency for changing oxygen tubing and the proper storage methods when not in use. The DON confirmed that oxygen tubing should be changed weekly, stored in a zip lock bag, and dated with the last change date, highlighting a failure in adherence to the facility's policy and manufacturer recommendations.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory values for a resident diagnosed with bipolar disorder. The resident was prescribed Lithium Carbonate Extended Release to manage their condition. A laboratory test conducted on November 1st revealed a low lithium level of 0.4, which was below the normal range of 0.6 to 1.3. However, there was no documentation indicating that the physician was informed of this low level, which was a requirement according to the facility's policy. Interviews with the Nurse Practitioner and the Director of Nursing confirmed that the nursing staff should have reported the low lithium level to the physician immediately. The Nurse Practitioner stated that if the difference was more than 0.1 from the normal range, the physician's office should have been notified, and the lab should have been rechecked within a week. The Director of Nursing acknowledged that the nursing staff should have reported the low level on the same day and that there was no audit system in place to ensure that out-of-range laboratory values were communicated to the physician.
Failure to Provide Routine and Emergency Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services to meet the needs of two residents, resulting in a deficiency. Resident #26, who was admitted to the facility without any teeth, had dentures that were too loose and had not been placed on the list to see a dentist. Despite being cognitively intact and having no documented dental issues in the Minimum Data Set (MDS), the resident expressed difficulty in keeping dentures in place and had not been seen by a dentist since admission. Resident #98, who had his own teeth and was cognitively intact, had broken or loose-fitting dentures and cavities. Despite a physician's order to see a dentist, the resident had not been seen by a dental provider and expressed concerns about teeth falling out. Observations confirmed multiple missing teeth and poor dental condition, yet the resident's care plan did not adequately address these issues, and the resident had not been scheduled for dental care. Additionally, Resident #27, who was edentulous and had no dentures, had not been offered dental services since admission. The Social Services Director (SSD) was responsible for scheduling dental appointments but was unaware of the residents' dental needs. Interviews with staff, including the SSD, Certified Medication Technician (CMT), Licensed Practical Nurse (LPN), and Director of Nursing (DON), revealed a lack of awareness and communication regarding the residents' dental concerns, contributing to the deficiency.
Resident Abuse by LPN in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse when an LPN was verbally and physically abusive towards the resident. The incident occurred when the LPN called the resident derogatory names, pulled the resident's hair, and kicked the resident while they were on a mattress on the floor. This resulted in a contusion to the resident's right hip and pain in their left knee. The resident, who has a history of mental health disorders including PTSD, bipolar disorder, and schizophrenia, was heard yelling and crying during the altercation and required an injection to calm their agitation. Multiple staff members witnessed the altercation but did not intervene. The resident's care plan indicated a need for a safe environment free from judgment and danger, and interventions for managing their mental health conditions. Despite this, the staff failed to follow the care plan and did not use de-escalation techniques or call for additional support. The resident's behavior escalated, leading to further aggression and property damage, but the staff did not effectively manage the situation. The facility's investigation revealed that the LPN was not supposed to be working on that unit and had not received de-escalation or CALM training. The LPN was eventually detained by the police and taken to jail. The resident expressed a desire to press charges against the LPN and stated they felt unsafe unless the LPN was removed from the unit. The incident highlights a significant failure in the facility's ability to protect residents from abuse and ensure a safe environment.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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