Hillside Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 1265 Mclaran Avenue, Saint Louis, Missouri 63147
- CMS Provider Number
- 265585
- Inspections on file
- 34
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Hillside Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide necessary behavioral health care and services for two residents with known self-harm and aggressive behaviors. One resident with quadriplegia, depression, anxiety, and a documented history of self-mutilation by finger biting had repeated episodes of biting his/her fingers to the point of severe lacerations, bone exposure, and eventual amputation, often linked to frustration and delayed smoking. Despite multiple hospitalizations and clear documentation of chronic self-harm and disruptive behavior, the care plan initially lacked self-injury interventions, no specific safety plan or intensive/1:1 monitoring was implemented, and there was no documented ongoing notification of psychiatry or the primary physician about escalating behaviors. Staff interviews showed that many staff knew of the resident’s chronic self-mutilation and verbal aggression but were unaware of any special interventions or monitoring requirements, and the resident was left alone in the room, hall, and on the patio, where another finger was bitten off. Another resident with aggressive behavior and repeated pulling of the fire alarm also lacked documented individualized behavioral interventions or psychiatric follow-up, contrary to the facility’s own Behavioral Emergency and Intensive Monitoring policies.
A resident with severe cognitive impairment, schizophrenia, traumatic brain injury, a significant UTI, and a documented history of behavior problems and physical aggression repeatedly assaulted three cognitively intact residents, including punching one in a hallway, striking another’s hand with a wheelchair foot pedal in a shared room (resulting in an acute metacarpal fracture), and punching a third in the face after accusing them of killing a baby. Staff and witness statements confirmed unprovoked attacks and the need for staff to physically intervene, yet nursing documentation lacked timely incident entries and clear rationale for behavior‑related assessments, and the behavior care plan contained only general interventions without identifying specific triggers or individualized de‑escalation strategies. Facility investigations repeatedly concluded the events were not caused by abuse or neglect and were not preventable or foreseeable, despite the resident’s known behavioral history and risk for physical aggression, and interviews indicated expectations for increased monitoring after altercations that were not consistently reflected in the medical record.
The facility failed to thoroughly assess and monitor multiple residents after injuries from altercations and to follow wound treatment orders. One resident with right hand pain and swelling after being struck by another resident had an x-ray showing a fractured metacarpal that was not reviewed for several days, and physician orders for a hand splint and ice were not implemented or documented, despite ongoing pain and visible swelling. Another resident punched in the head/face had no documented neuro checks or focused monitoring after the incident, even though a skull x-ray was obtained and the physician expected neuro assessments. Two additional residents with hand and toe wounds had physician-ordered daily wound care documented as completed on the TAR, but observations and resident reports showed dressings were not changed as ordered, wounds were left with unchanged or no dressings, and the DON was not informed of at least one new wound, contrary to facility wound care and intensive monitoring policies.
Staff failed to maintain resident dignity and privacy by talking down to cognitively intact residents, ignoring a resident’s request for additional food in front of the resident, and engaging in a screaming exchange with a resident. A resident with dementia and severe cognitive impairment was partially undressed with the room door open and no privacy curtain, leaving the resident’s breasts exposed to the hallway. Staff also violated the facility’s electronic device policy by using cell phones and Bluetooth devices while passing medications and at the nurse’s station, talking loudly about personal matters and engaging in video calls as residents walked by, and multiple residents reported that staff frequently used phones and ignored them.
Surveyors found multiple environmental deficiencies, including a repeatedly soiled toilet, dirty bathtub, and debris in a 300 south shower room that was not being cleaned as often as facility policy required, according to staff. A 300 south sitting room contained a smashed wall-mounted television that remained in place for an extended period after a resident damaged it, despite maintenance acknowledging it should be removed and replaced. On the 200 hallway, strong urine odors and sticky floors were repeatedly noted in the hallway and sitting room, with housekeeping citing short staffing and residents urinating in the sitting area. On 300 South, a shower room lacked functioning soap and paper towel dispensers, leaving no supplies for hand hygiene, and a resident room had loose floor tiles laid out on the floor and a television on the floor with its cord in the walkway, while maintenance and administration confirmed these conditions did not meet expectations for a homelike, safe environment.
The facility failed to ensure meals were served at safe and palatable temperatures, contrary to its policy requiring hot foods to be maintained at 135°F and reheated if below acceptable temperatures. Several residents, including individuals with diabetes, chronic kidney disease, and anorexia, reported that their food was frequently or usually cold, which discouraged eating for at least one resident. Surveyors observed breakfast and lunch service where hot items such as sausage, eggs, cream of wheat, pasta with meat, and mixed vegetables were served at temperatures between 80.7°F and 120°F and described as cold or lukewarm, with trays transported in uncovered carts and plates left uncovered. Staff, including dietary management and the Administrator, acknowledged that food was expected to be delivered at safe, palatable temperatures and returned to the kitchen if too cold, but this was not consistently done.
The facility did not maintain an effective pest control program, as mice were repeatedly observed in resident rooms and a hallway despite weekly contracted treatments and an existing pest control policy. A resident with schizophrenia and cognitive impairment had a live mouse in a trap behind a dresser, mouse-like droppings on clothing, and food and trash wrappers in a drawer, and reported mice crawling on them at night. Another cognitively intact resident with anorexia, bipolar disorder, PTSD, and depression had mouse-like droppings in a closet and reported multiple mice caught in glue traps. A third cognitively intact resident with paranoid schizophrenia, anxiety, and insomnia reported mice throughout a hallway, where a mouse was seen running into a medication room containing visible droppings. Staff, including an LPN, a CNA, and maintenance, reported reduced housekeeping hours, infrequent room cleaning, and certain rooms being hotspots for mice due to unclean belongings and food trash, showing that the pest control measures in place were not effectively preventing infestation.
The facility discontinued use of a long-time attending physician and did not allow that physician to continue providing care within the facility, despite residents’ stated wishes to keep this provider. According to the admission agreement, residents could select their own qualified healthcare professionals, but after the facility cited concerns about the physician’s failure to sign orders, complete Medicare certifications, and enter timely progress notes, residents were asked to transition to another physician. Cognitively intact residents reported being automatically reassigned to a new physician, described being upset about losing their long-standing physician and NP relationships, and said their questions about what happened to the prior physician were ignored or minimally addressed. A group of residents stated that a sheet was passed around informing them the physician had been dropped and a new doctor assigned, while leadership reported that residents could only continue seeing the former physician outside the facility, effectively preventing them from exercising their choice of attending physician for in-facility care.
Surveyors found that staff failed to review and implement multiple physician and hospital orders, including not transcribing or administering an ordered antibiotic for a UTI after a resident returned from the hospital, not applying a prescribed protective boot to a resident’s foot despite MAR entries indicating it was in place, and not acting on physician referrals for PT evaluations for two residents with mobility and pain issues. Observations, record reviews, and staff interviews showed missing orders in the ePOS and MAR, inaccurate documentation of device use, and lack of follow-through on therapy referrals, despite facility policy requiring accurate transcription and adherence to physician orders.
The facility failed to provide necessary ADL assistance, hygiene, and meal supervision to multiple residents. A resident who was fully dependent for toileting and always incontinent was left in a saturated brief and bed pad with urine and liquid stool for several hours, despite a care plan requiring frequent checks and incontinence care every episode. Another resident with impaired cognition and schizophrenia, needing supervised hygiene and setup for toileting, was repeatedly observed over several days with messy hair, long yellow fingernails, and wearing the same stained clothing, with no documentation of bathing or refusals, while staff reported clothing was not available on the unit. A third resident with severe cognitive impairment and multiple comorbidities, care planned for supervision while eating, was observed with meal trays and drinks placed out of reach while in bed and behind a closed door and drawn curtain, without staff supervision during meals.
A resident with impaired cognition, reduced mobility, chronic pain, diabetes, and identified risk for pressure injury developed an in-house Stage 2 pressure ulcer on the left buttocks. The physician ordered the wound to be cleansed, treated with TAO, and covered with a border gauze dressing BID, but observation found the wound open to air without a dressing. An LPN reported using barrier cream and keeping the wound open to air, while the DON stated the wound should have TAO and a bandage. The resident’s care plan did not reflect the presence of the Stage 2 pressure ulcer, and the care plan process had not been updated to include this new wound.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours each day, as required by regulation and its own staffing policy. Staffing records for a review period showed multiple days with no RN scheduled despite a census of 147 residents. The DON reported serving as the on-call RN on those days and believed this counted as RN coverage, although she was not physically present in the building for 8 hours and did not clock in due to being salaried. The Administrator acknowledged awareness of the requirement for daily RN coverage.
The facility failed to report an allegation of abuse to DHSS within the required timeframe after a verbal dispute between two residents escalated into a physical altercation. One resident, with severe cognitive impairment and multiple neurologic and cardiac diagnoses, was separated by nursing staff but repeatedly returned to the shared room, where an LPN later found the other resident standing over this resident, yelling. Both residents stated they had hit each other, and one resident requested hospital evaluation and voiced suicidal ideation, while the other reported being hit in the chest. The facility’s abuse policy required immediate reporting of all alleged abuse, including resident-to-resident physical altercations, yet no report was submitted to the state, and one resident’s record lacked documentation of the incident. The DON expected policy compliance, while the Administrator stated she was initially informed there had been no physical contact and therefore did not report the event.
The facility failed to thoroughly investigate an alleged abuse incident involving a physical altercation between two residents sharing a room. One resident with severe cognitive impairment and multiple diagnoses and another resident with psychiatric and neurologic conditions both later reported that they hit each other, and an LPN found one resident standing over the other, yelling, after being alerted by another resident. Although the facility’s abuse policy required immediate reporting, comprehensive documentation, and an administrative investigation with statements from all involved parties, there was no incident documentation or care plan updates for either resident, key witnesses were not interviewed or asked for written statements, and the Administrator did not document interviews that were obtained, resulting in a deficient investigation of the abuse allegation.
Staff did not continue wound care treatments for a resident after hospitalization, resulting in the worsening of a sacral pressure injury and the development of two additional pressure ulcers. Staff also failed to document wound changes accurately, notify the physician, and obtain updated wound care orders. Additionally, timely dressing changes were not performed for another resident with saturated dressings.
Staff failed to ensure two residents received appropriate pain management, including not administering prescribed pain medications for a resident with metastatic cancer and not providing adequate pain relief during wound care for another resident, resulting in significant pain for both individuals.
A resident with diabetes and peripheral vascular disease developed a wound on the right heel that was not documented in progress notes, physician order sheets, or treatment records. Facility staff failed to follow wound management protocols, including assessment, documentation, and obtaining physician orders, resulting in a lack of appropriate monitoring and care for the wound.
Staff failed to follow wound care policies for two residents, resulting in the worsening of pressure injuries and the development of new wounds. One resident did not receive continued wound care after hospital discharge, with missed documentation, lack of physician notification, and no wound care orders in place. Another resident with multiple pressure ulcers did not have dressings changed as ordered, with saturated dressings left in place for days. There was a lack of accurate documentation, failure to obtain or follow wound care orders, and improper application of treatments by CNAs without orders.
Two residents experienced unmanaged pain due to staff failing to administer prescribed pain medications, notify the physician when medications were unavailable, and follow pain management protocols. One resident with metastatic cancer was not given ordered narcotics and was transferred to the hospital for uncontrolled pain, while another resident with multiple wounds suffered significant pain during dressing changes and was given an over-the-counter spray without a physician order. Staff did not consistently assess, document, or communicate about pain as required.
A resident with diabetes and peripheral vascular disease developed a wound on the right heel that was not documented in progress notes, physician orders, or treatment records, despite being noted on a shift report. Staff were unaware of the wound, and required notifications and wound management procedures were not followed, resulting in a lack of physician orders and monitoring for the wound.
A resident with a legal guardian and multiple psychiatric diagnoses left the facility without authorization by disguising themselves as a visitor and exiting through a vulnerable front entrance. Staff failed to recognize or intervene, and there was confusion among staff regarding the difference between elopement and AMA, especially for residents with guardians. The facility's policies did not address this scenario, and required procedures for elopement were not followed, resulting in the resident's unauthorized departure.
Staff failed to ensure safe and appropriate oxygen administration for two residents, including not turning on oxygen for a resident with hypoxia and not following physician orders for oxygen flow rate and tubing changes for another resident. Observations showed improper setup, incorrect flow rates, and lack of proper labeling, contrary to facility policy and physician orders.
The facility failed to maintain handrails on resident halls, with observations revealing loose or missing handrails across multiple units. The Interim Regional Director of Maintenance was unaware of these issues, and the previous director noted that replacements were available but required a work order. The DON and Administrator were aware of missing but not damaged handrails, highlighting a gap in maintenance oversight.
The facility failed to provide a safe, clean, and homelike environment in two dining rooms and several common areas. The 300 main dining room had stained curtains, damaged chairs, and a trash bag on the floor. The 200 main dining room and day room had water leaks, with residents expressing concerns about slipping. The 200 hall had floor cracks, and the 100 hall had a soiled PPE container. Maintenance issues were not reported by staff, and the Interim Regional Director of Maintenance was unaware of the problems until the survey.
A resident receiving a bed bath in a shared room was left exposed to the hallway due to an open door and an unpulled privacy curtain. The resident, who required substantial assistance with personal hygiene, expressed a preference for the door to be closed during care. The ADON and DON confirmed that the door should have been closed and the privacy curtain pulled to ensure the resident's dignity and privacy.
The facility failed to follow physician orders for wound care for two residents, resulting in their hospitalization for wound conditions, including amputations. Despite having detailed orders, treatments were frequently missed, and the residents' conditions worsened. One resident, with a complex medical history, was found in distress with untreated wounds and was eventually hospitalized with infections. Interviews revealed systemic issues in treatment administration and documentation, with staffing problems cited as a reason for missed care.
A facility failed to administer enteral nutrition correctly for a resident dependent on a g-tube, leading to severe vomiting and hospitalization. The feeding machine was incorrectly set to 140 ml/hour instead of the prescribed 40 ml/hour. Additionally, g-tube site treatments were not completed as ordered for another resident, and staff failed to complete necessary assessments for self-administration of medications. Interviews revealed a lack of training and procedural guidance, contributing to the deficiencies.
A resident with epilepsy did not receive prescribed Keppra, leading to a seizure and hospitalization, while another resident was given Ambien despite a documented allergy. The facility failed to ensure medication availability and adherence to allergy checks, resulting in significant medication errors.
A resident with multiple pressure ulcers, including a Stage IV ulcer, did not receive consistent wound care and antibiotics as prescribed. The facility failed to administer Santyl and Gentamycin ointments and did not notify the NP or physician about missed treatments. This led to the resident's condition worsening, requiring hospitalization for surgical debridement and treatment of a severe infection.
The facility failed to timely identify and address significant weight loss in several residents, leading to inadequate nutritional interventions. A resident experienced a weight loss of -24.93% over a short period, with the facility failing to provide appropriate therapeutic diets, supplemental food items, and feeding assistance. Another resident, diagnosed with quadriplegia and malnutrition, also experienced significant weight loss due to inconsistent provision of nutritional supplements and inadequate assistance during meals. A third resident experienced a significant weight loss of over 10% within a few months, with prescribed supplements not documented or consistently provided.
The facility failed to provide appropriate respiratory care for a resident with COPD, resulting in hospitalization due to a delay in medication administration and reporting of a STAT chest x-ray. Additionally, the facility did not obtain physician orders for CPAP machines for two residents with sleep apnea, leading to inadequate care. The lack of communication and documentation regarding respiratory care needs contributed to the deficiencies.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week, as per their policy. Staffing sheets showed multiple dates without RN coverage, and interviews revealed reliance on agency staff and recruitment challenges. The Administrator expected the Staffing Coordinator to ensure compliance with RN coverage requirements.
The facility did not have a certified Director of Food and Nutrition Services, as the Dietary Manager lacked the necessary certification despite completing the course. The Registered Dietician only visits once a week and is not full-time, affecting all 151 residents consuming facility-prepared food.
The facility failed to conduct a thorough facility-wide assessment, missing critical details such as staffing ratios and the necessity for an RN for eight consecutive hours daily. The assessment also lacked documentation on the use of locked units for residents with cognitive impairments. Surveyors found insufficient nursing staff, missed treatments, and a lack of a restorative program, with no RN scheduled for the required hours.
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) due to a lack of a current tracking system and surveillance for antibiotics. The newly appointed Infection Preventionist (IP) was unaware of previous tracking information, and staff interviews revealed a lack of awareness and implementation of the ASP. The Administrator and DON acknowledged the expectation of antibiotic stewardship, but the responsibility to establish and maintain the ASP was not being fulfilled.
The facility did not maintain a tracking system for the mandatory 12-hour training requirements for CNAs. Five CNAs' records showed signed in-service sheets without time durations, and no tracking documentation was provided. A CNA and the Administrator confirmed the lack of official tracking despite ongoing education.
The facility failed to accommodate resident needs by not maintaining wheelchairs, providing necessary side rails, ensuring call light accessibility, and granting access to community rooms. Residents experienced discomfort and limited social interaction due to these oversights, highlighting a lack of communication and timely maintenance within the facility.
The facility failed to maintain a safe and homelike environment, with issues such as a leaking dining room ceiling, broken furniture, and the use of plastic utensils for meals. Additionally, a clogged toilet, damaged walls, dusty AC units, and a missing closet door were observed, indicating a lack of effective maintenance and housekeeping procedures.
The facility failed to conduct criminal background checks on three newly hired employees before their start dates, as required by policy. The HR representative admitted to delays in running these checks due to hectic circumstances, and the Administrator confirmed the expectation for timely checks. This oversight was identified during a review of employee files.
The facility failed to provide adequate personal care, nail care, and facial hair hygiene for several residents requiring assistance with ADLs. Observations revealed missed showers, strong odors, and visible hygiene issues due to staffing shortages and resident resistance. One resident with severe cognitive impairment missed multiple showers, while another with cerebral palsy had long nails and unwashed hair. Additionally, a resident with dementia had soiled bed linens unchanged for days, attracting flies. These deficiencies highlight the facility's failure to adhere to its care and services policy.
The facility failed to implement a restorative therapy program for residents with limited mobility, affecting three residents. A resident's therapy was discontinued due to insurance issues, and no restorative services were recommended. Another resident with severe cognitive impairment and range of motion limitations did not receive therapy or restorative services. A third resident with quadriplegia and dementia also did not receive therapy. The facility lacked an active restorative program, and the restorative aide was often pulled to work as a CNA due to staffing shortages.
The facility failed to provide sufficient nursing staff, resulting in missed wound care for two residents with complex medical needs. Staff interviews revealed consistent understaffing, leading to incomplete tasks and inadequate care. Despite efforts to use agency staff, the facility struggled to maintain safe staffing levels, impacting resident care.
The facility failed to serve food at safe and appetizing temperatures for three residents. A resident reported that their food was often cold upon delivery, while another resident with moderately impaired cognition also experienced cold meals. Observations confirmed that food items like waffles, hash browns, and fried chicken were served below the required temperatures. Staff interviews indicated an expectation for food to be delivered at appropriate temperatures.
The facility failed to maintain kitchen cleanliness and staff compliance with hygiene standards. Observations revealed grease and debris build-up on equipment, trash in the walk-in freezer, and dust on fans blowing on clean dishes. A staff member with a beard was repeatedly seen preparing food without a beard net, violating hygiene protocols.
A resident self-administered medications via a g-tube without a physician's order, contrary to facility policy. An LPN observed but did not educate the resident on safe administration techniques, leading to the injection of air into the stomach. The resident had a history of refusing staff-administered medications, and the DON was unaware of improper medication handling.
The facility failed to update resident inventory records, resulting in missing clothing for two residents. Issues in the laundry department, including staff changes and poor communication, contributed to the problem. Residents expressed dissatisfaction, with one washing clothes by hand to avoid further losses. The social worker and administrator were not fully aware of the missing items, highlighting a breakdown in the reporting process.
A resident with severe cognitive impairment repeatedly pulled the call light out of the wall, but this behavior was not documented in their care plan. Observations showed the call light unplugged with no audible alert at the nurse's station. Staff interviews revealed a lack of awareness and communication about the issue, contributing to the deficiency.
A resident with a history of stroke and bilateral leg amputations was transferred to another facility at their request, but the LTC facility failed to document the resident's involvement in the discharge planning process. Despite the Social Services Director's involvement, there was no record of the resident's decision or a Discharge Planning Assessment in the medical record.
A facility failed to complete a discharge summary for a resident transferred to another facility. The resident, with a history of stroke and bilateral leg amputations, was moved with medications and personal belongings, but there was no documentation of the transfer reason or a comprehensive discharge summary. Interviews revealed that the SSD did not document conversations or complete the summary, and the MDS nurse noted the discharge order but was not responsible for the process. The Administrator confirmed the SSD's responsibility for the summary, which was not completed as per policy.
A resident's room was found to contain hazardous chemicals, including Raid bug spray and Odoban and Febreeze sprays, despite staff expectations to keep rooms free from such items. The resident, with schizoaffective disorder and moderate cognitive impairment, had these items on their nightstand over several days. Staff interviews confirmed the expectation to monitor and remove harmful chemicals, highlighting a lapse in supervision and safety protocols.
Failure to Provide Behavioral Health Services for Residents With Self-Harm and Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services for residents with known self-harm and aggressive behaviors, specifically failing to develop and implement appropriate care plan interventions, safety planning, and timely psychiatric referrals. One resident with quadriplegia, depression, anxiety, and a documented history of self-mutilation by biting his/her fingers was admitted with prior PASRR documentation noting routine self-harm by biting the middle or index finger, prior hospitalization for a bite wound infection, and staff reports that mental health follow-up would be arranged. The admission MDS identified self-directed behavioral symptoms occurring several days and placing the resident at significant risk for physical injury and interference with care. Despite this, the care plan initially contained no interventions for self-injury in January or February, and there were no behavioral monitoring orders or documented safety plan specific to the resident’s finger-biting behavior. Following admission, multiple episodes of self-harm occurred, with staff repeatedly observing the resident biting his/her right-hand fingers, causing bleeding, open lacerations, and progressive damage to the bone, resulting in repeated transfers to the hospital. Progress notes document that the resident bit his/her middle finger shortly after admission, leading to hospital transfer for a self-inflicted wound, and later reopened the wound by biting, again requiring hospital care. Subsequent notes describe the resident biting his/her finger to obtain a cigarette, biting to the point of bone exposure, and stating an intention to continue biting until the finger fell off. Staff documented ongoing verbal abuse, yelling, cursing, and difficulty redirecting the resident, but there was no consistent documentation of behavioral interventions, no evidence of intensive monitoring or 1:1 observation in the facility record, and no documented safety plan addressing triggers such as smoking delays or frustration. Although the care plan was later updated to include a generic focus on risk for self-directed violence and listed interventions such as assessing self-harm thoughts, developing a written safety plan, and referring to psychiatric services, the electronic medical record contained no actual safety plan or specific, implemented interventions related to the resident’s finger-biting behavior. The facility also failed to ensure timely and ongoing psychiatric involvement despite repeated self-harm episodes. A psychiatry NP completed an initial assessment noting the resident’s history of self-harm by finger biting, verbal aggression, and irritability, and directed staff to monitor and promptly report any self-harm behaviors. However, after this encounter there were no further psychiatry notes, and the record contained no documentation that psychiatry or the primary care physician were notified of the resident’s ongoing and escalating self-mutilation. Hospital documentation later identified psychiatric diagnoses including delirium and antisocial personality disorder, with associated complications of agitation, violence, self-injurious behavior, impulse control problems, and poor insight and judgment, and specifically indicated that continuous 1:1 observation was required due to risk of harm to self. When the resident returned from the hospital with a surgical dressing and a recent history of finger amputation, staff interviews revealed that no 1:1 or enhanced monitoring was implemented, staff were unaware of any special interventions, and the resident was left alone in his/her room or in the hall and on the patio. During a supervised smoking period, the resident became agitated about delays in smoking, was briefly left unattended, and bit off another finger. Multiple CNAs, a restorative aide, an activities aide, a CMT, and nursing staff stated that everyone knew about the resident’s chronic self-mutilation and disruptive behaviors, yet they were not aware of any specific interventions, 1:1 monitoring, or safety plan in place to prevent further self-harm. In addition, the facility failed to address another resident’s aggressive behavior and repeated pulling of the facility fire alarm. This resident’s behavior included aggressive actions and multiple instances of activating the fire alarm, but the report does not describe any individualized behavioral interventions, monitoring plans, or psychiatric referrals implemented to address these behaviors. The facility’s own Behavioral Emergency and Intensive Monitoring policies require early non-physical interventions, assessment of residents in behavioral crisis, notification of physicians or psychiatrists, updating care plans, and use of intensive or 1:1 monitoring for residents with poor impulse control, self-harm, or aggressive behaviors. Despite these policies, the documented actions and staff interviews show that these processes were not effectively carried out for the residents in question, leading to repeated self-mutilation events for one resident and unaddressed aggressive and alarm-pulling behavior for another. The Administrator was notified that an Immediate Jeopardy situation existed related to these failures, beginning on 4/21/26, based on the facility’s failure to provide necessary behavioral health services, to implement care plan interventions and safety planning for known self-harm behaviors, and to timely involve psychiatric services, resulting in repeated episodes of self-mutilation by finger biting and unaddressed aggressive and alarm-pulling behavior.
Failure to Prevent and Manage Resident-to-Resident Physical Abuse by a Behaviorally High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse and to adequately identify, monitor, and care plan for escalating aggressive behaviors. One resident with severe cognitive impairment, schizophrenia, traumatic brain injury, and a documented history of behavior problems and physical aggression was involved in several unprovoked physical altercations with three cognitively intact residents. The resident’s care plan noted a history of delusional and accusatory behaviors, including accusations that staff and peers were choking or hurting them, and a prior behavior of throwing themself on the floor. Interventions focused on medication administration, monitoring for side effects, anticipating needs, and general communication strategies, but there was no documentation of specific behavioral triggers or individualized de‑escalation strategies. A urinalysis collected for undocumented reasons showed a significant E. coli UTI, and an antibiotic was started; however, there was no documentation of increased behaviors prior to the lab draw and no clear linkage in the record between the infection and behavior monitoring. On one date, the aggressive resident physically attacked another resident in the hallway. Witness statements from a CMT and a CNA documented that the aggressor stood up and punched the other resident several times while the victim was trying to get into their room, and staff had to intervene to break up the fight. The aggressor later stated they were angry and acknowledged they should not have fought, but could not identify staff they felt safe talking to. The victim reported that the aggressor approached in the hall, stood up, and knocked their hat off, and that staff came running before the victim could respond. The facility’s investigation concluded that the aggressor was the aggressor and was sent out for evaluation, but also concluded that the incident was not caused by abuse or neglect, was not preventable, and was not a foreseeable ongoing problem despite the resident’s documented behavioral history and risk for physical aggression. There was no contemporaneous nursing documentation of the altercation on the date it occurred, even though subsequent notes described bruising and swelling to the aggressor’s face and forehead attributed to that date. On another date, the same aggressive resident struck two additional residents. One victim reported that the aggressor came into their room, closed the door, hit their right hand with a wheelchair foot pedal, and that the victim then pushed the aggressor over the bed and other items before leaving the room. The victim later complained of right hand pain and swelling, and imaging showed an acute fracture of the fourth metacarpal with significant angulation and displacement; there was no documentation in the progress notes of the cause or events leading to this injury. The second victim reported being punched in the face in the hallway after the aggressor accused them of killing their baby; this resident stated the punch caused ongoing pain, and a skull x‑ray was obtained, which was unremarkable. The facility’s investigation documented that the aggressor hit both residents unprovoked, that one assault in the room was unwitnessed and only discovered through statements, and that the aggressor had a UTI and was on antibiotics. The care plan was updated to add generic interventions such as assessing for pain and injury, skin assessments, room changes, and staff redirection, but it did not identify specific triggers or concrete strategies for staff to use to prevent or de‑escalate physically aggressive episodes. Interviews with nursing staff and leadership indicated that the resident had been moved from a locked behavioral unit to another floor, that staff observed the resident “being different” around the time of the UTI and fights, and that after altercations the resident was supposed to be on increased monitoring for 72 hours, yet the record lacked consistent documentation of such monitoring or of proactive interventions to prevent further resident‑to‑resident abuse.
Failure to Assess, Monitor, and Follow Treatment Orders After Injuries and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment, monitoring, and treatment following resident-to-resident altercations and for wounds, contrary to physician orders and facility policies. After a physical altercation, one resident sustained right hand pain and swelling and received an x-ray on 4/18/26, with results reported on 4/19/26 showing an acute fracture of the right fourth metacarpal neck with significant angulation and mild displacement. The facility did not review these x-ray results until 4/24/26, and staff, including the ADON and nurses, were unaware of the fracture during that period. Although the physician reported ordering a hand splint, ice, and an orthopedic consult, there was no evidence that the splint and ice orders were implemented, and staff monitoring of the hand was either undocumented or not performed as described, despite the resident’s ongoing complaints of pain and visible swelling and limited ability to make a fist. Another resident was struck in the head/face by another resident in a hallway altercation. The resident reported being punched on the left side of the face and continued to report pain. An order was obtained for a skull x-ray, which was completed and read as unremarkable. However, the medical record contained no documentation of neurological checks or ongoing monitoring of the resident’s injury and pain after the incident, despite the physician’s expectation that neuro checks be initiated for a head strike and the DON’s statement that 72-hour monitoring following a resident-to-resident altercation was expected as standard nursing judgment. Progress notes only reflected general skin checks with no specific neuro or focused injury assessments, and there was no documentation of PRN pain medication use for this resident during the review period. The facility also failed to provide and document wound treatments in accordance with physician orders and its wound management policy for two other residents. One resident returned from the hospital with sutures to the right hand and had an order to cleanse the sutured area with normal saline, apply triple antibiotic ointment for two days, then cover with Vaseline daily until healed. The TAR showed treatments documented as completed over multiple days, but observations on several dates revealed the same white surgical dressing from the hospital remained in place without removal or ointment application, and the resident reported that no staff had changed the dressing until the resident removed it personally after several days. Another resident sustained a facility-acquired open wound to the right second toenail bed after the toenail was pulled off during care. An order was in place to clean the wound with wound cleaner, apply wound gel, cover with an ABD pad, and wrap with Coban daily, and the TAR showed treatments signed as completed daily. However, observations on multiple dates showed the toe without any dressing, with the resident stating that staff only dressed the toe for the first few days and then left it open to air, and the LPN later confirmed she had been leaving the wound open to air while still uncertain about signing off the treatment. The DON stated she had not been informed of the toe wound and expected staff to notify her of new skin issues and any changes in treatment. The facility’s own policies on intensive monitoring and wound treatment management required assessment, monitoring, and documentation tailored to residents in crisis or with behavioral issues, and evidence-based wound care in accordance with physician orders, including documentation of treatments and changes. In the cases reviewed, residents involved in altercations and those with wounds did not receive thorough assessments, consistent monitoring, or documented treatments as ordered. Care plans for the residents involved in altercations referenced assessment for pain and injury and skin assessments, but the actual records lacked the detailed follow-through, such as neuro checks, ongoing pain assessments, and documented wound care, that would align with those plans and the facility’s stated expectations. Overall, the deficiency centers on the facility’s failure to thoroughly assess and monitor residents after injuries from altercations, failure to promptly review and act on diagnostic results, and failure to follow and document wound treatment orders, despite clear physician directives and facility policies. These failures were confirmed through resident interviews, staff interviews, record review, and direct observations of untreated or inconsistently treated injuries and wounds.
Failure to Maintain Resident Dignity, Privacy, and Attention Due to Disrespectful Communication and Cell Phone Use
Penalty
Summary
The deficiency involves multiple failures by staff to treat residents with dignity and respect, and to communicate appropriately. One cognitively intact resident with anorexia, bipolar disorder, PTSD, and major depressive disorder reported that staff talked down to him/her and others on the hallway, and that staff did not treat him/her like an adult. Another cognitively intact resident with chronic kidney disease, disorganized schizophrenia, bipolar disorder, anxiety, and major depressive disorder requested more food after lunch; a CNA told the resident dietary would be called, but when the dietary aide arrived at the nurse’s station, the aide stated in front of the resident that he/she was too busy to get the food and that the CNA should go to the kitchen. The resident began to cry, stated he/she was hungry and questioned why food could not be brought, while the dietary aide ignored the resident and walked away. A third cognitively intact resident with chronic kidney disease, schizophrenia, bipolar disorder, anxiety, and major depressive disorder was observed in a room where both the resident and a CNA were screaming at each other, and the CNA later admitted yelling back at the resident to “match the resident’s energy,” acknowledging this was inappropriate. The facility also failed to provide privacy during personal care for a resident with Alzheimer’s disease, dementia, muscle weakness/wasting, chronic kidney disease, and severe cognitive impairment. This resident was observed sitting on the edge of the bed with the room door open and the privacy curtain tucked away while a CNA changed the resident from pajamas to clothing. During this care, the resident’s breasts were exposed to the hallway. The CNA later stated he/she had been in a hurry to get residents up and acknowledged that the door should have been closed before undressing the resident to maintain dignity and privacy. In addition, the facility did not ensure staff followed its electronic device policy while providing care and medications. A CMT was observed at the medication cart and inside a resident’s room wearing an earpiece and talking loudly on the phone about needing money while administering medications. A sign posted on the unit stated “no Bluetooth zone” and reminded staff of no phone use in residential areas, yet a cognitively intact resident on that unit reported that staff ignored the sign, used phones frequently, and that a CMT had been on the phone and “fussing” that morning. Another CNA was observed at the main nurse’s station laughing and engaged in a video call on a cell phone while residents walked past. Ten residents in resident council interviews confirmed seeing staff with earpieces or AirPods talking on the phone every day and on weekends, and reported that staff continued phone conversations and ignored residents.
Failure to Maintain Clean, Odor-Free, and Homelike Environment in Multiple Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple areas of the building. Surveyors observed the 300 south hallway shower room on several occasions and found the toilet repeatedly soiled with brown and yellow matter and the bathtub dirty with hair, along with debris on the floor. Housekeeping staff reported that bathrooms were supposed to be cleaned twice daily and as needed, but a CNA stated that housekeeping hours had been cut since new ownership, resulting in bathrooms not being cleaned as often as needed. The Administrator stated she expected the 300 south shower room to be cleaned once a day and as needed, and that housekeeping was responsible for cleaning bathrooms and resident rooms. Additional observations showed environmental deficiencies in common areas and resident rooms. In the 300 south hallway sitting room, a wall-mounted television remained smashed with a cracked screen over multiple days, despite the Maintenance Director acknowledging awareness of the issue and stating it should be removed and replaced. The Administrator reported that maintenance staff were responsible for fixing or reporting broken appliances and that the television had been broken since a resident threw a chair at it months earlier. On the 200 hallway, surveyors repeatedly noted a strong urine odor and sticky floors in the main hallway and sitting room. A housekeeper stated that the area should be clean and odor-free but was only cleaned once a day due to short staffing, and that some residents urinated in the sitting room instead of the bathroom. The Administrator confirmed that nursing staff cleaned bodily fluids and housekeeping sanitized afterward, and she expected the hallway to be free from odors and sticky floors, while acknowledging that some residents used the sitting room instead of the bathroom. Further environmental issues were identified on 300 South and in a specific resident room. On multiple observations, the first shower room on 300 South had detached paper towel and soap dispensers, with no paper towels or soap bottles available for residents to wash their hands. A maintenance worker stated that housekeeping was responsible for the holders, that residents had ripped them off the wall, and that the front desk had a plan to keep them stocked. In one resident room, several floor tiles had been removed and were laid out on the floor, including in front of the bed, and a television was on the floor next to the window with its cord in the walkway. The Maintenance Director acknowledged that the removed tiles on the floor did not make a homelike environment and said he needed adhesive to reattach them, and he reported he had not received work orders for the broken dispensers or missing toilet paper holder in the second shower room. The Administrator stated that maintenance was responsible for fixing broken items and that she expected the loose tiles to be removed from resident areas and the broken dispensers and missing toilet paper holder to be repaired and holes patched.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure food and beverages were served at safe and palatable temperatures, as required by its dietary food preparation policy dated 7/5/23, which specified that warm foods should measure at 135°F and that items not at acceptable serving temperatures should be reheated or chilled to proper temperatures. Multiple cognitively intact and moderately cognitively impaired residents reported that their meals were frequently or usually cold. One resident with type 2 diabetes stated the food tasted terrible and was always cold. Another resident with chronic kidney disease reported that food was most always cold when delivered. A resident with anorexia stated that food was most always served cold and that this contributed to not wanting to eat. Additional residents reported that food was served cold a lot of the time or could sometimes be cold. Surveyor observations of meal service confirmed that food was not consistently maintained at appropriate temperatures. During a breakfast observation on the 300 south hallway, meals were served in Styrofoam boxes, and measured temperatures showed a sausage patty at 81.5°F, scrambled eggs at 80.7°F, and cream of wheat at 118°F, all described as cold. At a lunch observation on the 200 hallway, the room tray cart was uncovered and plates had no coverings, with pasta and meat measuring 120°F and described as lukewarm, and mixed vegetables at 108°F and described as cold. Interviews with the Regional Certified Dietary Manager, another staff member, and the Administrator confirmed that facility expectations and policy were for food to be delivered at safe and palatable temperatures and that staff should return food to the kitchen if it was too cold, indicating that these expectations were not met in practice.
Ineffective Pest Control Program Resulting in Ongoing Mouse Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent mice infestation, despite having a written policy and weekly contracted pest control services. The policy required a comprehensive pest control program, regular outside service, appropriate chemical use, a reporting system for issues between visits, and treatment of both interior and exterior areas. Pest control logs showed frequent treatments and trap replacement over several weeks, and the pest control technician reported that the company was focusing on mice and had recommended that resident rooms be kept clean and free of food trash. However, staff interviews revealed that housekeeping hours had been cut under new ownership, resulting in resident rooms not being cleaned as frequently as needed, and that certain rooms were known hotspots for mice. Surveyor observations and resident interviews documented ongoing mouse activity affecting multiple residents and areas. One resident with schizophrenia, chronic pain syndrome, mild intellectual disabilities, and moderately impaired cognition had a live mouse in a trap behind the dresser, brown sprinkle-shaped substances on clothing in a drawer, and food and trash wrappers in the same drawer; the resident reported that mice were always around the room and crawled on them at night. Another cognitively intact resident with anorexia, bipolar disorder, PTSD, and major depressive disorder had brown sprinkle-shaped matter in the closet and reported seeing mice in the room, including two recently caught in a glue trap. A third cognitively intact resident with paranoid schizophrenia, anxiety, and insomnia reported mice “all over” a specific hallway, and surveyors observed a mouse running across that hallway into the medication storage room, where mouse droppings were seen on the floor. Staff, including a CNA and maintenance, acknowledged that there were mice throughout the area and that one resident’s room was a hotspot due to unclean belongings, demonstrating that the pest control program was not effective in preventing mice.
Failure to Honor Residents’ Choice of Attending Physician After Discontinuing a Provider
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when it discontinued services with Physician RR and did not permit this physician to continue providing care within the facility. The admission agreement stated that residents may select qualified healthcare professionals who conform to facility policies and applicable laws and that the facility may require credentialing. It also stated the facility may assist residents in selecting another physician if a physician fails or refuses to meet statutory or regulatory requirements. The facility issued a letter, dated 4/10/26 and signed by the administrator, stating that Physician RR continued to fail to sign orders, complete Medicare certifications, and timely enter progress notes, and that residents under this physician’s care were being asked to transition to alternative physicians. Resident #133, cognitively intact with diagnoses including anemia, heart failure, hypertension, stroke, anxiety, depression, and a psychotic disorder, had been under the care of Physician DD as primary physician and Nurse Practitioner SS as alternate, and was his/her own responsible party. The resident reported receiving the letter about Physician RR and stated that residents were upset because they had been with Physician RR for many years. The resident said that when he/she asked staff what happened to Physician RR, staff ignored the question, and when he/she asked social services, he/she was simply told that the new physician was Physician DD. An LPN reported that Resident #133 wanted to keep Physician RR and had a rapport with this physician, but the resident was transitioned to the new physician instead of being allowed to continue with Physician RR in the facility. Resident #139, also cognitively intact with diagnoses including hypertension, anxiety, depression, schizophrenia, PTSD, and asthma, was his/her own responsible party and had Physician DD documented as primary physician. This resident stated that many residents wanted to keep Physician RR, but they were automatically enrolled with Physician DD whether they wanted to or not, and the resident chose not to contest the change despite a long-standing rapport with Nurse Practitioner SS. In a group interview, nine residents reported that the facility “dropped” Physician RR about a month earlier and passed around a sheet stating they were not using Physician RR and had a new doctor. The DON stated that Physician RR was difficult to reach, did not sign orders or return calls, and was no longer the facility’s primary physician as of the prior month, while also stating there were no residents who expressed feelings about losing Physician RR. The administrator reported that residents received 30 days’ notice of the primary physician change and that residents could continue to see Physician RR only outside the facility, indicating that residents who wished to retain Physician RR for in-facility care were not allowed to do so.
Failure to Implement and Follow Physician and Hospital Orders for Medications, Protective Devices, and Therapy Referrals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician and hospital orders were reviewed, transcribed, and implemented according to professional standards. For one resident with severely impaired cognition and multiple psychiatric and neurologic diagnoses, hospital discharge instructions documented concern for a urinary tract infection and included an order for Cephalexin 500 mg by mouth four times daily for seven days. This antibiotic order was not entered into the electronic physician order sheet or the medication administration record, and there was no documentation in the progress notes explaining the resident’s hospital transfer or return. The DON stated she was unaware of the discharge instructions and that the resident returned from the hospital after she had left for the day. Another resident with severely impaired cognition, muscle weakness, lack of coordination, abnormal posture, and a history of stroke had an active physician order for a cushion boot to the right foot while out of bed for daily protection. Observations on two separate days showed the resident without the protective boot, and the resident reported that staff never put the boot on. Despite this, the MAR documented that the protective boot was on per order on those same days. A CNA reported never seeing protective boots on the resident, and an LPN confirmed the resident did not have a protective boot. Additionally, a physician progress note for this resident directed encouragement of participation in PT for mobility and contracture management, which the Director of PT/OT identified as a referral for therapy, but the resident was not evaluated. A third resident with impaired cognition, reduced mobility, chronic pain, and diabetes had a care plan addressing left shoulder pain and limited physical mobility, but the mobility problem lacked documented goals or interventions. A physician progress note for this resident instructed encouragement of a PT evaluation for mobility and knee rehabilitation for management of shoulder pain. Review of the electronic physician orders and nursing progress notes showed no current order for a PT evaluation and no documentation that such an evaluation was pursued. The DON stated she expected staff to follow facility policy for transcribing and following physician orders and indicated that the DON and ADON were responsible for auditing physician orders and for ensuring that new or referral orders were communicated to the physician as needed.
Failure to Provide ADL Assistance, Hygiene, and Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), including toileting and incontinence care, for a resident who was fully dependent on staff. One resident, cognitively intact but dependent for toileting hygiene, bathing, dressing, and bed mobility, and always incontinent of bowel and bladder, was observed lying in bed with a saturated brief and bed pad containing urine and liquid stool. The resident’s care plan required staff to change disposable briefs as needed, clean the peri-area with each incontinent episode, and check the resident as needed. A CNA reported the resident was last changed around 9:30 A.M., and the resident stated that night shift usually changed them before 6:00 A.M. and they were not changed again until around noon, despite being on a water pill and having recent diarrhea. Staff interviews, including with the DON and LPN, confirmed the expectation that incontinent residents be checked every two hours and kept clean, dry, and odor free. The deficiency also includes failure to provide hygiene assistance and appropriate grooming for another resident with impaired cognition, schizophrenia, reduced mobility, muscle weakness, and unsteady gait, who required partial to moderate assistance with personal hygiene, bathing, toileting, and dressing. The resident’s care plan indicated supervision with hygiene and toilet assistance with setup. A care plan meeting note documented that the resident needed a haircut, shave, nail trimming, and additional clothing, with staff to follow up. However, there was no documentation of refusals of hygiene assistance or of bathing assistance provided. Over multiple days of observation, the resident was repeatedly seen with messy hair, long yellow fingernails, and wearing the same stained white t‑shirt and jeans, and the resident stated that fingernails needed to be cut and clothes changed. CNAs reported that most residents did not have clothes available on the floor because the elevators were down and laundry had not brought clothes up, and that this resident was scheduled for showers on specific days. Additionally, the facility failed to provide required supervision during meals for another resident with severe cognitive impairment and multiple diagnoses including diabetes, muscle weakness, chronic kidney disease, dementia, depression, heart failure, and reduced mobility. The resident’s MDS and care plan required supervision while eating. Observations showed the resident in bed with a tray of untouched food on a bedside table placed out of reach, and on another occasion attempting unsuccessfully to reach a drink on a bedside table positioned out of reach, with the privacy curtain pulled and the room door closed. Later, the resident was observed with a plate of breakfast on the lap while drinks remained out of reach on the bedside table, again with the curtain pulled and door closed. A CNA stated the resident sometimes needed encouragement to come to the dining room and preferred to eat in the room, and that staff were expected to supervise the resident during meals. The Administrator and DON stated staff should supervise the resident during meals when indicated on the care plan and ensure bedside tables, food, and drinks were within residents’ reach.
Failure to Provide Ordered Pressure Ulcer Treatment and Update Care Plan
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment and to update the care plan for a resident who developed an in-house Stage 2 pressure ulcer. The resident had impaired cognition, required maximal assistance with ADLs, had reduced mobility, chronic pain, and diabetes, and was identified as at risk for pressure injury on the MDS. A wound report documented that the resident developed a new, in-house Stage 2 pressure ulcer on the left buttocks. The physician’s order dated 04/06/26 directed staff to cleanse the left buttocks wound with soap and water, pat dry, apply triple antibiotic ointment, and cover with a border gauze dressing twice daily at 9:00 A.M. and 5:00 P.M. The TAR showed the treatment was documented as provided for 28 of 29 opportunities, with the last recorded treatment on 04/21/26 at around 9:00 A.M. On observation on 04/22/26 at 4:20 P.M., the resident’s left buttocks wound had no dressing and was open to air, with surrounding discoloration, contrary to the physician’s order requiring TAO and a covered dressing. During interview, an LPN stated the resident had two small open areas on the backside and that staff were to apply barrier cream at night and keep the wound open to air, and reported the wound had been discovered a couple of weeks earlier. In contrast, the DON/treatment nurse stated the wound should have TAO and a bandage over it and acknowledged the resident did not have a bandage on. Additionally, review of the resident’s care plan in use at the time of survey showed it did not reflect the presence of the Stage 2 pressure ulcer, and the care plan designee stated that care plans are updated every 90 days and revised on specific days, indicating the resident’s new pressure ulcer had not been incorporated into the care plan after its discovery.
Failure to Ensure Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulation and by its own Sufficient Staffing Policy dated February 2023. The policy states that the facility must provide licensed nursing staff 24 hours a day, 7 days a week, and, except when waived, must use the services of an RN for at least 8 consecutive hours daily, 7 days a week, taking into account census, acuity, and resident diagnoses. Review of staffing sheets for March 2026 showed multiple days with no RN scheduled, specifically on 3/1, 3/7, 3/9, 3/14 through 3/17, 3/21, 3/22, and 3/25, despite a census of 147 residents and a sample of 8 residents reviewed. In interviews, the DON stated she was the on-call person for the days when no RN was scheduled and believed that on-call status would count as RN coverage, acknowledging she was in the building at times on those days but not for eight hours. The Administrator stated awareness that an RN needed to be scheduled for at least eight hours a day, seven days a week, and it was noted that the salaried DON does not clock in when on duty, contributing to the lack of documented RN coverage.
Failure to Timely Report Resident-to-Resident Physical Altercation as Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe following a physical altercation between two residents. The facility’s Abuse and Neglect policy required that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately to the Administrator and appropriate agencies within prescribed time frames, and defined abuse to include certain resident-to-resident altercations and physical abuse such as hitting and punching. Despite this policy, review of the DHSS reporting system showed no documentation that the facility submitted a report regarding the physical altercation between the two residents. Resident #1 had severe cognitive impairment and diagnoses including heart failure, cerebral palsy, and stroke. Nursing notes documented that a verbal disagreement between Resident #1 and his/her roommate, Resident #2, escalated, requiring the nurse to physically separate them and move Resident #1 to the hallway; however, Resident #1 repeatedly returned to the room, and staff were later called back for a “fight.” LPN A found Resident #2 standing over Resident #1, yelling, and both residents stated they had hit each other. Resident #1 later reported being hit and hitting back, and Resident #2 reported being hit in the chest. Resident #1 was kept near the nurse’s station for safety and expressed a desire to go to the hospital and voiced suicidal ideation. Resident #2’s record contained no documentation of the altercation. The DON stated she expected the Abuse and Neglect policy, including timely state reporting, to be followed and did not know why reporting did not occur. The Administrator stated she was initially told there was no physical contact and therefore did not believe the incident needed to be reported to DHSS.
Failure to Thoroughly Investigate Resident‑to‑Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse arising from a physical altercation between two residents. The facility’s Abuse and Neglect policy requires that all allegations of abuse, including resident‑to‑resident altercations, be immediately reported to the Administrator and other appropriate agencies, and that an administrative investigation be completed with statements from all involved staff and residents, documentation of pertinent information, and identification of root cause. Despite this policy, the facility did not complete a comprehensive investigation after an incident in which two residents reported hitting each other. Resident #1, who had severe cognitive impairment and diagnoses including heart failure, cerebral palsy, and stroke, was documented in a nurse’s note as having an altercation with his/her roommate, Resident #2. The note described a verbal disagreement that escalated, with the nurse initially separating the residents and moving Resident #1 to the hallway, then later finding Resident #2 standing over Resident #1, yelling, after being called back because it was reported as a fight. Resident #1 requested hospital evaluation and voiced suicidal ideation, and management was notified. However, there was no care plan documentation regarding the altercation, and the medical record contained no evidence of a completed incident report or a documented administrative investigation as required by policy. In a later interview, Resident #1 stated that another resident hit him/her and he/she hit back. Resident #2, who had no documented cognitive impairment and diagnoses including hypertension, Alzheimer’s disease, seizure disorder, schizophrenia, and depression, also had no care plan or medical record documentation of the altercation. Resident #2 reported that Resident #1 hit him/her in the chest. Another resident, Resident #8, cognitively intact with anxiety and schizophrenia, reported hearing two residents arguing and notifying an LPN, but stated no one had asked him/her about the incident before the survey interview. The LPN reported finding Resident #2 standing over Resident #1, being told by both residents that they hit each other, separating them, and notifying the on‑call ADON, but was not asked to write a statement. The ADON stated he/she was only told there was an argument, not a physical altercation, and the Administrator acknowledged not interviewing Resident #1 and not documenting interviews obtained from others. The DON stated the Abuse and Neglect policy was expected to be followed, including accurate information and gathering statements, but could not explain why this did not occur, resulting in a failure to conduct the thorough investigation required by facility policy.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
Staff failed to follow the facility's wound care policy for a resident who returned from hospitalization with an identified sacral pressure injury. After discharge, wound care treatments were not continued as required, leading to the worsening of the existing sacral wound and the development of two additional pressure injuries. Staff did not ensure accurate documentation of the wounds, failed to notify the physician about the worsening condition since hospitalization, and did not obtain updated wound care orders. Additionally, for another resident, staff did not perform timely wound dressing changes for saturated dressings. These failures were identified through observation, interview, and record review, and involved a total facility census of 145 residents.
Failure to Provide Effective Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for two residents. For one resident with metastatic breast cancer and bone involvement, staff did not ensure the resident received prescribed pain medications as ordered by the physician and did not notify the primary physician when pain medications were not delivered from the pharmacy or when medications were available in the emergency kit. This resident experienced uncontrolled pain and was transferred to the hospital two days after admission. For another resident, staff did not provide effective pain relief during wound care, as wound dressings adhered to the wound sites were removed without adequate pain management, causing the resident to cry out in pain and request over-the-counter Bactine spray for relief. These deficiencies were identified through observation, interview, and record review, and involved a sample of 16 residents out of a census of 145.
Failure to Obtain Physician Orders and Monitor Wound
Penalty
Summary
Facility staff failed to obtain physician orders and monitor a wound identified on a resident's right heel. The resident, who had diagnoses of diabetes and peripheral vascular disease, was dependent on staff for personal hygiene and mobility. Although a wound was noted on the facility's 24-hour shift report, there was no documentation in the resident's progress notes, physician order sheet, or treatment administration record regarding the wound. Additionally, shower sheets did not reflect the presence of the wound, and some documentation was missing for the relevant period. The facility's wound management policy required licensed nurses to assess, document, and report wounds, obtain physician orders, and initiate appropriate treatment. It also required notification of the interdisciplinary team and responsible parties, as well as regular documentation of wound status and care. In this case, these procedures were not followed, as there was no evidence of wound assessment, physician notification, or initiation of treatment for the wound on the resident's right heel. Interviews with facility staff, including the CNA, ADON, and DON, revealed a lack of awareness and communication regarding the wound. The wound was only identified during a skin assessment conducted by the DON, ADON, and a wound care nurse practitioner, who described it as a diabetic ulcer secondary to pressure. Staff interviews confirmed that the expected documentation and notification processes were not carried out.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to follow its wound care policy for two residents, resulting in the worsening of existing pressure injuries and the development of new wounds. For one resident with quadriplegia, Parkinson's disease, diabetes, and reduced mobility, staff did not continue wound care treatments after a hospital discharge, despite clear hospital orders for wound care and nutritional supplements. The initial re-admission skin assessment and subsequent weekly assessments did not accurately document the presence or progression of wounds, and there was no evidence of physician notification or new wound care orders. The resident reported that no treatments were applied to his/her wounds after returning from the hospital, and staff interviews confirmed that wound care orders were missed and not carried over from the hospital. The resident's wounds worsened, with multiple open, bleeding areas observed, and a wound care specialist was not consulted until weeks later. Additionally, staff failed to ensure timely dressing changes for another resident with multiple pressure ulcers and severe protein malnutrition. Although wound care orders specified daily dressing changes and as needed for saturation, observations revealed saturated dressings that had not been changed for several days, and one wound was left uncovered. The resident and a CNA reported that wound dressings were not changed as ordered, and there was no documentation of wound care or dressing changes in the progress notes during the observed period. Throughout the incidents, there was a lack of accurate documentation, failure to notify physicians of worsening wounds, and failure to obtain or follow wound care orders. Staff also did not ensure the use of pressure-reducing devices for residents at risk, and CNAs applied treatments without proper orders. The facility did not have a dedicated wound care nurse, and floor nurses were expected to manage wound care, but failed to do so according to policy. These failures led to the worsening of wounds and the development of additional pressure injuries.
Failure to Provide Effective Pain Management for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services. For one resident with metastatic breast cancer and severe pain, staff did not ensure that prescribed pain medications, including morphine and oxycodone, were administered as ordered. The resident's pain medications were not delivered from the pharmacy, and staff did not notify the primary physician about the delay or about the availability of pain medications in the emergency kit. Documentation showed that the resident experienced severe, uncontrolled pain, with pain scores as high as 10/10, and was ultimately transferred to the hospital two days after admission due to uncontrolled pain. Interviews revealed confusion among staff regarding the process for obtaining and administering pain medications from the emergency kit, and there was evidence that medications were marked as given in the records when they had not actually been administered. Another resident with quadriplegia, Parkinson's disease, and multiple wounds experienced significant pain during wound care. Staff removed wound dressings that were adhered to the wound sites, causing the resident to cry out in pain and request the use of an over-the-counter pain-relieving spray (Bactine) on the wounds. The aides applied the spray at the resident's request, despite there being no physician order for its use. There was no evidence that the nurse was notified of the resident's pain during the dressing change, nor was there documentation of a pain assessment or physician notification regarding the increased pain related to the wounds. The facility's own pain management policy required timely pain assessments, administration of pain medications as ordered, and physician notification if pain was not controlled or medications were unavailable. In both cases, these procedures were not followed. Staff failed to assess, document, and manage pain effectively, and did not communicate with the physician or utilize available resources to address the residents' pain, resulting in unmanaged pain and inappropriate administration of non-ordered medications.
Failure to Obtain Physician Orders and Monitor Wound for Resident with Diabetes and PVD
Penalty
Summary
Facility staff failed to obtain physician orders and monitor a wound identified on a resident with a history of diabetes and peripheral vascular disease. The resident required moderate to maximum assistance with activities of daily living and had no documented foot ulcers or wounds upon admission or in subsequent care plan updates. However, a wound to the right heel was noted on a 24-hour shift report, but there was no corresponding documentation in the resident's progress notes, physician order sheet, or treatment administration record for the period reviewed. Shower sheets for the resident did not document the presence of a wound on the right heel, and some shower sheets for the relevant week were missing. When the resident was assessed by the DON, ADON, and a wound care nurse practitioner, a wound was observed on the back of the right foot above the heel, described as a diabetic ulcer secondary to pressure. The wound measured 0.6 cm by 0.6 cm by 0.3 cm depth, with 90% granulation and 10% slough. Interviews with staff revealed a lack of awareness and communication regarding the wound. The CNA who assisted with the resident's shower was unaware of the wound, and the ADON had not been informed nor seen documentation of the wound. The DON stated that the expectation was for nurses to notify the physician, obtain treatment orders, and inform relevant parties when a wound is identified, but this process was not followed in this case.
Failure to Prevent Elopement and Ensure Staff Understanding of Policies for Residents with Guardians
Penalty
Summary
A deficiency occurred when a resident with a legal guardian, multiple psychiatric diagnoses, and a history of elopement risk left the facility without authorization or proper supervision. The resident, who was not permitted to leave the facility per the guardian's request, managed to exit the building by disguising themselves as a visitor and leaving through the front entrance, which had a known security vulnerability. Staff, including the receptionist, did not recognize the resident or intervene, and the resident was able to leave the premises and enter a waiting vehicle without staff knowledge or proper discharge procedures being followed. Facility staff demonstrated inconsistent understanding and application of policies regarding elopement, wandering, and discharge against medical advice (AMA). Interviews revealed confusion among staff about the distinction between elopement and AMA, particularly for residents with guardians who are not permitted to make independent medical decisions. Documentation showed that the resident was considered to have left AMA, and the guardian was contacted after the resident had already left. However, the facility's policies did not address the specific scenario of a resident with a guardian leaving without authorization, and staff failed to follow the established procedures for elopement, such as immediate intervention, thorough documentation, and care plan updates. The investigation further revealed gaps in staff training and policy implementation. Several staff members, including the ADON, LPN, and activity staff, provided conflicting accounts of the incident and the resident's risk status. The facility's documentation lacked statements from key staff involved, and there was no evidence that the required steps for managing elopement were followed. The resident's care plan did not document a history of wandering or elopement risk, despite information from staff that the resident had a known tendency to run off. The facility's failure to provide adequate supervision and to ensure staff understood and followed policies for residents with guardians led to the resident's unauthorized departure.
Failure to Ensure Safe and Appropriate Oxygen Administration
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for two residents requiring oxygen therapy. In one instance, a resident with a history of COPD, asthma, and dementia returned from a canceled medical procedure exhibiting shortness of breath and low oxygen saturation levels. Staff placed the resident on supplemental oxygen, but Emergency Medical Services (EMS) later found that the oxygen was not turned on, resulting in continued hypoxia. Upon EMS intervention, the resident's oxygen saturation improved after the oxygen was properly administered. In another case, a resident with multiple diagnoses, including heart failure, respiratory failure, and mild cognitive impairment, was observed with oxygen tubing and a nasal cannula on the floor, and the oxygen flow rate set significantly higher than the physician's order. The tubing was not properly labeled or dated as required by facility policy, and the oxygen was set at 7 to 8 liters per minute, despite orders for 2 liters per nasal cannula as needed for shortness of breath. Staff interviews confirmed that the oxygen should have been set at the prescribed rate and that any changes should be communicated to nursing leadership and the physician. The facility's own oxygen administration policy requires verification of physician orders, correct setup and flow rate, proper labeling and dating of tubing, and regular monitoring and documentation. Observations and interviews revealed that these procedures were not consistently followed, resulting in deficiencies in respiratory care for residents requiring oxygen therapy.
Deficient Handrail Maintenance in Facility
Penalty
Summary
The facility failed to ensure that handrails on each resident hall were properly maintained, which had the potential to affect all residents. Observations on various units revealed multiple instances of loose or missing handrails. On the 100 South unit, several handrails were either detached, missing screws, or completely absent between rooms and outside key areas such as the soiled utility room and shower room. Similar issues were noted on the 100 Main, 200 Main, 300 Main, and 300 South units, with missing end caps and loose handrails being common problems. Interviews with facility staff revealed a lack of awareness and communication regarding the state of the handrails. The Interim Regional Director of Maintenance, who had just started, was unaware of the issues and had not yet assessed the equipment. The previous maintenance director acknowledged the problem and mentioned that replacement handrails were available but required a work order through the TELs system. The Director of Nursing and Administrator were aware of the missing handrails but not the damaged ones, indicating a gap in the facility's maintenance oversight and reporting processes.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of its three dining rooms and several common areas. In the 300 main dining room, there were large brown stains on the curtains, a wet spot on the floor with a yellow substance, and chairs with torn or detached seats. Residents were observed sitting on damaged chairs, and a trash bag was placed directly on the floor for waste disposal. In the 200 main dining room, water was leaking onto the floor, and residents expressed concerns about the risk of falling due to the wet conditions. Staff occasionally placed towels to absorb the water but often did not take any action. In the 200 main day room, the carpet was wet, and residents, including those in wheelchairs, were sitting in the wet area. One resident's socks were wet from the carpet, and they expressed concern about slipping. The 200 hall had large cracks in the floor, and the 100 hall had a soiled PPE container. The Interim Regional Director of Maintenance, who started recently, was unaware of these issues until the survey and noted that the building had bad seals on the windows and roof, contributing to the leaks. Interviews with the Director of Nursing and Administrator revealed that they were not informed of the leaks or the condition of the chairs until the survey. Staff had not reported these issues through the facility's maintenance request system. The previous Regional Director of Maintenance was also unaware of the chair conditions and the extent of the water leaks. The facility lacked a policy to address maintenance duties, and there was no record of staff reporting the leaks or damaged equipment.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident during incontinence care. The incident involved a resident who was cognitively intact and had multiple diagnoses, including deep venous thrombosis, neurogenic bladder, septicemia, seizure disorder, and anxiety. The resident required substantial assistance with personal hygiene and was bedfast most of the time. During an observation, the resident was receiving a bed bath in a shared room with the door open and the privacy curtain not pulled, leaving the resident exposed to the hallway and visible to passersby. The resident expressed a preference for the door to be closed during care, although they were not concerned about the privacy curtain due to the same-gender roommates. The Assistant Director of Nursing (ADON) confirmed that it was inappropriate for the door to be open during personal care, and the Director of Nursing (DON) and Administrator agreed that personal care should be provided with the door closed and the privacy curtain pulled. The incident highlighted a failure to maintain the resident's right to privacy and dignity as outlined in the resident bill of rights.
Failure to Follow Wound Care Orders Leads to Hospitalization
Penalty
Summary
The facility failed to obtain and follow physician orders for wound care for two residents, leading to their hospitalization for wound conditions, including amputations. The facility's wound management policy outlines procedures for assessment, treatment, and documentation of wounds, but these were not consistently followed. For Resident #89, there were multiple instances of missed wound care treatments as documented in the Treatment Administration Record (TAR) and progress notes. Despite having detailed physician orders for wound care, including specific instructions for cleansing, applying medications, and dressing wounds, the TAR showed numerous blank entries where treatments were not administered. Notifications to the Nurse Practitioner (NP) about missed treatments were made, but no new orders were received, and the resident was eventually hospitalized with infections and wounds requiring further medical intervention. Resident #89 had a complex medical history, including heart failure, diabetes, and obesity, which contributed to their vulnerability to skin integrity issues. The resident was noted to be resistive to care, often removing dressings and scratching wounds, which exacerbated their condition. Despite this, the facility's staff failed to consistently document and follow up on the resident's refusal of care or missed treatments. Observations revealed the resident in distress, with actively bleeding wounds and an inability to call for help due to a malfunctioning call light. The resident reported not receiving treatments for several days, and the room was noted to have an odor of urine and feces, indicating neglect in care. Interviews with facility staff, including the DON and LPN responsible for wound care, revealed systemic issues in the administration of wound treatments. The DON acknowledged that treatments were not completed and emphasized the need for documentation and communication with physicians when residents refuse care. However, there was a lack of awareness and follow-through on missed treatments, and the facility's staffing issues were cited as a reason for the inability to carry out treatment orders. The resident's condition deteriorated to the point of requiring hospitalization, where they were found to have a blood infection and were placed on IV antibiotics.
Inappropriate Administration of Enteral Nutrition via G-Tube
Penalty
Summary
The facility failed to provide appropriate administration of enteral nutrition for a resident dependent on a gastrotomy tube (g-tube). The resident's physician's orders specified a continuous feeding rate of 40 ml/hour with water flushes of 175 ml every four hours. However, the tube feeding machine was not set in English and was incorrectly set to infuse at a rate of 140 ml/hour. This error resulted in the resident receiving approximately 400 cc of feeding in a short period, leading to severe vomiting and subsequent hospitalization. The facility also failed to ensure that g-tube site treatments were completed as ordered for another resident. Additionally, the staff did not complete a self-administration medication assessment and obtain physician's orders for self-administration of medications via g-tube. The facility's policies on feeding tube site care and physician's orders were not adequately followed, contributing to the deficiencies observed. Interviews with staff revealed a lack of awareness and training regarding the correct settings and operation of the g-tube machine. The DON and other nursing staff were not informed about the machine's incorrect settings in a timely manner, and there was no policy in place to guide staff on setting up the tube feeding pump or hanging the feeding container. This lack of communication and procedural guidance contributed to the failure in providing appropriate care for residents with feeding tubes.
Medication Errors and Allergy Oversight in LTC Facility
Penalty
Summary
The facility failed to administer the prescribed medication, Keppra, to a resident with epilepsy, resulting in a significant medication error. The resident, who had a history of epilepsy, intellectual disability, dementia, schizophrenia, and anxiety, was admitted to the hospital after experiencing a grand mal seizure and sustaining a fracture of the right fibular shaft. The medication administration record indicated that the Keppra was not available on multiple occasions, and the resident did not receive the medication as ordered. Despite documentation indicating the medication was given, progress notes revealed that the medication was not available, leading to the resident's seizure and subsequent hospitalization. Another resident with known allergies to several medications, including Ambien, was administered Ambien despite the allergy being documented in the medical record. The resident's medical history included mild cognitive impairment, high blood pressure, wound infection, septicemia, hip fracture, anxiety, and depression. The medication administration record showed that Ambien was given on multiple occasions, and there was no documentation of any adverse reactions or symptoms following its administration. Interviews with staff revealed a lack of awareness and adherence to checking for allergies before administering medications. The facility's failure to ensure the availability and administration of prescribed medications, as well as the administration of a medication to which a resident was allergic, constituted significant medication errors. These errors were identified during a survey, and the facility was notified of the immediate jeopardy situation. The deficiency was initially determined to be at the immediate jeopardy level, indicating a serious threat to the health and safety of the residents involved.
Failure to Administer Wound Care and Antibiotics
Penalty
Summary
The facility failed to provide adequate care for a resident with pressure ulcers, resulting in a significant deficiency. The resident, who was cognitively intact and required substantial assistance for daily activities, had multiple pressure ulcers, including a Stage IV ulcer on the coccyx. The facility did not consistently administer prescribed wound treatments and antibiotics, as evidenced by multiple undocumented and missed applications of Santyl and Gentamycin ointments. Additionally, the facility failed to notify the attending wound Nurse Practitioner (NP) or the physician about these missed treatments. The resident's condition worsened, leading to a hospital admission for surgical debridement of the sacral wound. The hospital's infectious disease physician had prescribed a regimen of antibiotics, which the facility did not administer consistently. The facility's records showed numerous instances where the antibiotics were not given, and there was no documentation of physician notification regarding these omissions. Interviews with facility staff, including the Director of Nursing and the wound care NP, confirmed that the facility had significant issues with completing wound care and administering medications as ordered. The failure to provide consistent wound care and medication administration resulted in the resident developing a severe infection, requiring hospitalization. The facility's wound nurse and the specialty wound care NP both highlighted the importance of adhering to treatment orders and the risks associated with untreated wounds. Despite these concerns, the facility did not take appropriate action to ensure the resident received the necessary care, leading to the deficiency noted in the report.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to timely identify and address significant weight loss in several residents, leading to inadequate nutritional interventions. Resident #127 experienced a weight loss of -24.93% over a short period, with the facility failing to provide appropriate therapeutic diets, supplemental food items, and feeding assistance. The resident's medical history included malnutrition, dysphagia, and cognitive impairment, which contributed to poor food intake. Despite physician orders for nutritional supplements and ice cream, these were inconsistently provided, and the resident often refused facility food, preferring food brought by family. Observations showed the resident frequently spit out food, and staff did not consistently offer alternatives or encouragement during meals. Resident #123, diagnosed with quadriplegia and malnutrition, also experienced significant weight loss. The resident required maximum assistance for eating, but staff often left the resident unattended during meals, resulting in poor intake. Although the resident was prescribed nutritional supplements, these were not consistently provided with meals. The resident's family declined tube feeding, and the facility's dietary management failed to ensure the resident received the necessary nutritional support, contributing to ongoing weight loss. Resident #50, with diagnoses including malnutrition and schizophrenia, experienced a significant weight loss of over 10% within a few months. The resident was prescribed Boost supplements between meals, but there was no documentation of this order in the medication records. The facility's care plan did not address the resident's weight loss, and dietary staff failed to document the provision of supplements. Observations indicated that the resident's nutritional needs were not adequately met, contributing to the continued weight loss.
Deficiency in Respiratory Care and Equipment Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with COPD, resulting in a deficiency. The resident, who had severe cognitive impairment and multiple diagnoses including COPD, experienced a change in condition and was sent to the hospital. The facility did not administer the ordered oral steroids in a timely manner, and there was a delay in obtaining and reporting the results of a STAT chest x-ray, which revealed pneumonia. The resident's condition worsened, leading to hospitalization where they were diagnosed with a COPD exacerbation and received necessary medications. Additionally, the facility failed to obtain physician orders for CPAP machines for two residents diagnosed with sleep apnea. One resident, who had no cognitive impairment and was diagnosed with heart failure and respiratory failure, used a CPAP machine during resting hours but lacked a physician's order for its use. The resident's CPAP mask was often found uncovered, and there was no documentation of the CPAP settings or diagnosis for its use. Another resident, with diagnoses including heart failure and COPD, also lacked physician orders for CPAP and oxygen therapy, despite using these devices. The resident's CPAP machine was reported broken, and there was no follow-up to obtain a replacement or notify the physician. The facility's failure to ensure proper medication administration and obtain necessary physician orders for respiratory equipment contributed to the deficiencies identified. The lack of communication and documentation regarding the residents' respiratory care needs and the unavailability of medications and equipment further exacerbated the situation, leading to inadequate care for the affected residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by their policy. The facility's staffing sheets from June 1 to July 9, 2024, revealed multiple dates with no RN coverage, specifically on June 1, 2, 15, 16, 17, 18, 19, 20, 21, 22, 23, 29, 30, and July 6, 7. During interviews, the Staffing Coordinator acknowledged the lack of RN coverage and mentioned the use of agency staff to fill the gaps. The Administrator expressed an expectation for the Staffing Coordinator to ensure RN coverage and noted ongoing recruitment efforts, including sign-on and referral bonuses, due to the difficulty in recruiting RNs.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Director of Food and Nutrition Services, which is a requirement for ensuring the proper management of dietary services. The Dietary Manager, who was hired on September 29, 2022, did not possess the necessary certification from the Association of Nutrition and Food Service Professionals, as he had completed the course but had not taken the certification exam. This lack of certification was confirmed during an interview with the Dietary Manager. Additionally, the facility's Administrator acknowledged that the Registered Dietician only visits the facility once a week and is not employed full-time, further emphasizing the absence of a certified full-time dietary manager. This deficiency had the potential to impact all 151 residents who consumed food prepared by the facility.
Incomplete Facility-Wide Assessment and Staffing Deficiencies
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment lacked critical details such as staffing ratios required per shift to meet resident needs, the necessity for a Registered Nurse (RN) to be present for at least eight consecutive hours a day, seven days a week, and the facility's use of locked units for residents with cognitive impairments and behaviors. The facility's assessment, updated on 12/13/23, was incomplete, missing documentation on direct care staff ratios, restorative therapy staff, social services staff, dietary staff, housekeeping, and laundry staff necessary for each shift. Additionally, there was no documentation regarding the need for an RN or the use of locked units for residents with specific needs. During the survey, it was identified that the facility had insufficient nursing staff to meet resident needs, as evidenced by staff interviews and reports of missed treatments and activities of daily living (ADL) care for residents. Furthermore, the facility did not schedule an RN for the required eight consecutive hours a day, seven days a week, and lacked a restorative program. The Administrator acknowledged that the facility assessment is developed by the Administrator and reviewed by the facility's Regional office and interdisciplinary team, and it is expected to accurately reflect staffing needs and resources, including the use of locked units.
Deficiency in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to establish an effective Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and a system to monitor antibiotic use. The facility's ASP, revised on 10/24/22, outlined procedures for limiting antibiotic resistance, improving treatment efficacy, and reducing treatment-related costs. However, the facility did not have a current tracking system or surveillance for antibiotics. The Infection Preventionist (IP) and Medical Director were responsible for setting standards for antibiotic use, but the newly appointed IP was unaware of the previous tracking and surveillance information. The facility's Minimum Data Set (MDS) Nurse, who recently took over the ASP and IP role, did not have access to the previous tracking system, indicating a lapse in continuity and oversight. Interviews with facility staff revealed a lack of awareness and implementation of the ASP. The Wound Nurse expressed a need for an antibiotic log or tracking system to refine care plans for residents with infected wounds, but was unaware of the existence of a current ASP. The Administrator and Director of Nursing (DON) acknowledged that antibiotic stewardship was expected to be utilized to track and monitor residents with antibiotic orders, but the responsibility to establish and maintain the ASP was not being fulfilled. This deficiency highlights a significant gap in the facility's infection control practices, as evidenced by the absence of a functional ASP and the lack of a systematic approach to monitor antibiotic use among residents.
Failure to Track CNA Training Hours
Penalty
Summary
The facility failed to establish and maintain a tracking system for the mandatory 12-hour training requirements for Certified Nursing Assistants (CNAs). This deficiency was identified for five sampled CNAs out of a census of 151. The facility did not provide a policy related to the 12-hour training requirement. A review of the training records for the sampled CNAs showed multiple dated in-services and education sheets signed by the CNAs, but these documents did not list the duration of each in-service. Furthermore, there was no documentation provided by the facility to track the in-services for each CNA. During interviews, a CNA mentioned that the facility was always providing in-services and education but did not officially track the mandatory 12 hours. The Administrator acknowledged that while education and in-services were provided, there was a failure to organize and track the yearly mandatory training hours for the CNAs.
Facility Fails to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents, leading to multiple deficiencies. Three residents were found to have wheelchairs in poor condition, with damaged armrests and improper fitting, causing discomfort and potential harm. Despite being aware of these issues, staff did not report them for repair in a timely manner. Additionally, one resident was not provided with side rails for bed mobility and positioning, despite having a physician's order and assessment indicating their necessity. The lack of communication and follow-through on maintenance requests contributed to these deficiencies. Another resident was found without access to a call light, which was stuck and unreachable, leaving the resident unable to call for assistance. This oversight was not addressed by staff, despite the resident's care plan emphasizing the importance of call light accessibility to prevent falls and ensure safety. The facility's failure to ensure the call light was within reach posed a significant risk to the resident's well-being. Furthermore, the facility restricted access to community rooms on the third floor, preventing residents from engaging in social activities and watching television. The rooms were locked due to excessive heat, and the television in one room was broken, yet these issues were not promptly addressed. This lack of access limited residents' ability to socialize and participate in preferred activities, impacting their quality of life. The facility's inaction in addressing these environmental concerns further exemplifies the failure to accommodate residents' needs and preferences.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. On the first floor, the dining room ceiling was leaking, with water collecting in a bucket on the floor, creating an unsafe and unhomelike environment for the 33 residents present. The issue had been ongoing since April, with significant damage noted by a roofing company, yet the problem persisted during the survey period. Additionally, the second floor common areas were found to have furniture in disrepair, including a loveseat missing a leg and a reclining chair with exposed stuffing, which residents and staff acknowledged had been in poor condition for an extended period. The facility also failed to provide a homelike dining experience on the second floor, where residents were served meals with plastic utensils, making it difficult for them to eat certain foods. This practice was attributed to concerns about regular utensils not being returned to the kitchen and a shortage of supply, despite the facility having enough silverware. The use of plastic utensils was not considered homelike, and residents expressed difficulty in eating their meals properly. Furthermore, the third floor shower room had a clogged toilet with fecal material and flies, which had been left unaddressed for weeks, indicating a lack of communication and reporting among staff. Additional deficiencies included a resident's bedroom wall being damaged and not reported for repair, AC units in several rooms being covered in dust and debris, and a resident's closet door missing, leading to concerns about privacy and security. These issues were not promptly reported or addressed by the staff, highlighting a breakdown in the facility's maintenance and housekeeping procedures. The facility's policies and procedures for maintaining a safe and operable environment were not effectively implemented, resulting in an environment that was not conducive to the residents' well-being.
Failure to Conduct Timely Background Checks on New Hires
Penalty
Summary
The facility failed to perform criminal background checks (CBC) on newly hired employees prior to their start date, as required by the facility's policy. This deficiency was identified for three out of ten employees hired since the last survey. The facility's Staff Screening policy, revised on October 24, 2022, mandates that criminal background screening and reference checks be conducted for prospective staff, contractors, consultants, registry/temporary staff, and volunteers before employment or contract commencement. However, the review of employee files revealed that CBCs were not requested or received for a Certified Nurse Aide, a Dietary Aide, and a Maintenance Assistant, all of whom were hired between November 2023 and March 2024. Instead, Family Care Safety Registry (FCSR) checks were run on July 10, 2024, well after their hire dates. Interviews with facility staff highlighted the oversight in conducting timely background checks. The Human Resources (HR) representative acknowledged her responsibility for running pre-employment background checks, including CBCs or FCSRs, before new hires start working. She admitted that due to hectic circumstances, background checks were sometimes delayed and not immediately saved in employee files. The Administrator confirmed the expectation that HR should complete these checks before employment begins and retain them in the employee files. This lapse in procedure led to the deficiency noted by the surveyors.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide adequate personal care, nail care, and facial hair hygiene for five residents who required assistance with activities of daily living (ADL). Observations and interviews revealed that residents were not receiving showers as scheduled, and there were instances of missed showers, resulting in residents emitting strong odors and having visible hygiene issues. For example, one resident with severe cognitive impairment and a fungal infection was noted to have missed approximately seven showers, and staff reported difficulties in providing showers due to staffing shortages and resident resistance. Another resident with severe cognitive impairment and multiple diagnoses, including cerebral palsy and quadriplegia, was observed with long nails and a buildup of dirt, as well as white flakes in their hair, indicating a lack of regular hygiene care. The resident's care plan required substantial assistance for personal hygiene, but there was no documentation of showers being provided in July 2024. Staff interviews indicated that nail care and hair washing were not consistently performed, and the resident's hygiene needs were not adequately met. Additionally, a resident with moderate cognitive impairment and diagnoses of schizoaffective disorder and dementia was found with soiled bed linens that had not been changed for at least three days, attracting flies. Staff interviews confirmed that bedding should be changed daily or as needed, but this was not consistently done. The facility's failure to adhere to its care and services policy, which mandates sufficient staffing and individualized care plans, contributed to these deficiencies in resident care.
Failure to Implement Restorative Therapy Program
Penalty
Summary
The facility failed to fully implement the restorative therapy program for residents with limited mobility, affecting three residents. Resident #88's therapy was discontinued due to insurance issues, and no restorative services were recommended. The resident had a hand contracture, and although therapy recommended a hand splint, it was not ordered. Observations showed the resident lying in bed with contracted hands and no hand splint worn. The resident reported not receiving therapy or restorative services and required staff assistance for mobility. Resident #4 had severe cognitive impairment and functional range of motion limitations but did not receive therapy or restorative services. The care plan indicated a need for assistance with transfers and maintaining mobility, but no restorative program was established. The resident reported not receiving therapy services and had a contracted right hand, requiring full care assistance from staff. Resident #123, with quadriplegia and dementia, also did not receive physical, occupational, or restorative therapy. The care plan focused on maintaining the current level of function, but no restorative program was established. Observations showed the resident with contractures to the hands and upper arms. Interviews revealed that the facility did not have an active restorative program, and the restorative aide was often pulled to work as a CNA due to staffing shortages.
Inadequate Staffing Leads to Missed Wound Care in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, resulting in inadequate wound care for two residents. Resident #89, with a history of cellulitis, diabetic foot ulcer, and multiple other conditions, had several wound care orders that were not carried out due to the nurse-to-patient ratio being too high. Similarly, Resident #2, who had multiple pressure ulcers and infections, also did not receive the necessary wound treatments. The lack of adequate staffing was documented by LPN L, who reported being unable to complete wound treatments due to being the only nurse on the floor. Interviews with various staff members, including LPNs, CNAs, and the Staffing Coordinator, revealed a consistent theme of understaffing across all shifts. Staff members reported having to prioritize tasks, often leaving wound care and other essential duties incomplete. The facility's staffing sheets showed multiple days without RN coverage, further exacerbating the issue. The DON and Administrator acknowledged the staffing challenges but noted that they had not been made fully aware of the extent of the problem by the staff. The facility's staffing policy aimed to ensure adequate nursing personnel, but the actual staffing levels did not meet the needs of the residents, particularly those requiring wound care. The facility's census exceeded the average daily census, increasing the demand for nursing care. Despite efforts to use agency staff and adjust schedules, the facility struggled to maintain safe staffing levels, impacting the quality of care provided to residents.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature for three residents, as observed during a survey. Resident #30, who is cognitively intact, reported that their food was cold most of the time when delivered to their room. Resident #58, with moderately impaired cognition, also stated that their food was usually delivered cold. Resident #111, who is cognitively intact, mentioned that their food was almost always cold upon delivery. These observations were made during interviews conducted on July 8, 2024. Further observations on July 11 and July 15, 2024, revealed that food items served on the second floor were below the acceptable serving temperatures as per the facility's policy. For instance, waffles, hash browns, and fried chicken were served at temperatures significantly lower than the required 135 degrees Fahrenheit. Similarly, breakfast items such as sausage patties, eggs, and oatmeal were also served at inadequate temperatures. Interviews with staff, including the Dietary Manager and the Administrator, confirmed that there was an expectation for food to be delivered at appropriate temperatures to ensure residents received hot meals.
Kitchen Hygiene and Staff Compliance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and hygiene standards in the kitchen, as observed over several days. The kitchen equipment, including the deep fryer and tilt skillet, had significant grease and debris build-up. The walk-in freezer was found with trash and food debris on the floor, and the flour and sugar bulk bins had lids caked with a white powder substance. Additionally, a fan in the dishwashing room was observed with dust build-up, blowing on clean dishes and silverware. These observations were made on multiple occasions, indicating a consistent lack of adherence to the facility's cleaning protocols. Furthermore, staff failed to comply with personal hygiene standards during food preparation. A staff member with a beard approximately 3/4 of an inch long was observed preparing food without wearing a beard net on multiple occasions. This was noted during both breakfast and lunch preparations, where the staff member handled cooked eggs, chicken, and mixed veggies without the required protective gear. Interviews with the dietary staff and management confirmed that all dietary staff are responsible for cleaning duties and that beard nets are mandatory during food preparation to prevent contamination.
Failure to Ensure Safe Self-Administration of Medications via G-Tube
Penalty
Summary
The facility failed to ensure a resident was properly assessed and demonstrated the ability to safely self-administer medications via a gastric tube. The resident, who was cognitively intact and had a history of severe protein-calorie malnutrition, bipolar disorder, depression, PTSD, and anxiety, self-administered medications without a physician's order to do so. The facility's policy required an assessment and a physician's order for self-administration, which was not obtained in this case. During an observation, an LPN prepared the resident's medication, including crushing a Protonix tablet, which should not have been crushed, and handed it to the resident to self-administer through the g-tube. The resident injected the medication with a large amount of air into the stomach, which was not in accordance with safe medication administration practices. The LPN did not provide necessary education or cues to the resident about the risks of injecting air or the proper technique for administering medication via gravity. Interviews with staff revealed that the resident had a history of refusing medications if staff attempted to administer them, and the resident needed constant reminders about the correct procedure. The DON stated that a resident should have an order to self-administer medication and fluids through a g-tube, and staff should document refusals and notify management and the doctor. The DON was unaware that the Protonix was being crushed, indicating a lack of communication and oversight in the medication administration process.
Failure to Update Resident Inventory Leads to Missing Clothing
Penalty
Summary
The facility failed to update the records of residents' personal possessions according to its policy, resulting in missing clothing items for two residents. Resident #42 had purchased dresses and socks that were not documented on the inventory sheet and were missing after being sent to the laundry. Similarly, Resident #39 had purchased shirts and pants that were not documented and were also missing after laundry service. The facility's policy requires that items brought into the facility after admission be added to the resident inventory at the request of the resident or their representative, but this was not adhered to in these cases. Interviews and observations revealed that the facility's laundry services were experiencing significant issues, including a lack of communication between nursing staff and laundry staff, leading to misplaced or lost clothing. The laundry aides reported that they had to reorganize the laundry area due to a high volume of lost clothing and that clothing often arrived without proper identification. Additionally, the facility had recently let go of most of its laundry staff, leading to further disorganization and confusion. The residents expressed dissatisfaction with the handling of their clothing, with one resident resorting to washing clothes by hand to prevent further losses. The facility's social worker and administrator were not fully aware of the extent of the missing clothing issue. The social worker was unaware of the missing clothing for the residents involved, and the administrator was only aware of one resident's missing items. The facility's policy requires that missing items be reported to social services, who then report to laundry, but this process was not effectively followed. The lack of proper inventory updates and communication breakdowns contributed to the deficiency in managing residents' personal possessions.
Failure to Address Resident's Call Light Behavior
Penalty
Summary
The facility failed to address a specific behavior of a resident related to pulling the call light out of the wall, which was not included in the resident's care plan. The resident, who has severe cognitive impairment and multiple diagnoses including Alzheimer's disease, was observed multiple times with the call light unplugged, and the notification light above the door was lit without an audible sound at the nurse's station. Despite these observations, there was no documentation in the medical record or care plan addressing this behavior. Interviews with staff revealed that the call light was removed due to the resident's behavior, and alternative notification methods like bells were mentioned but not effectively implemented. The Director of Nursing and Administrator were unaware of the issue, and the Regional Director of Plant Operations and Director of Maintenance were not informed about the call light being removed. This lack of communication and documentation contributed to the deficiency in addressing the resident's behavior and ensuring a functioning call light system.
Failure to Document Resident Involvement in Discharge Planning
Penalty
Summary
The facility failed to document a resident's involvement in discharge planning, which is a requirement according to their Transfer and Discharge Planning policy. The policy mandates that Social Services staff conduct a Discharge Planning Assessment and document the resident's involvement in the discharge process. However, for a resident who was transferred to another facility, there was no documentation of the resident's involvement in the decision to transfer, nor was there a Discharge Planning Assessment filed in the resident's medical record. The resident, who had a history of stroke, atrial fibrillation, and bilateral leg amputations, was transferred to another facility at their request to be closer to their previous home. Despite the Social Services Director's involvement in the discharge planning, there was no documentation of conversations with the resident regarding their request to transfer. The Administrator confirmed that the transfer was the resident's choice and expected documentation to reflect the resident's involvement in the discharge planning process.
Failure to Complete Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. The resident, who had a history of stroke, atrial fibrillation, and bilateral leg amputations, was transferred to another facility with medications and personal belongings. However, there was no documentation related to the reason for the transfer, whether the resident was involved in the discharge planning, or a comprehensive final discharge summary of the resident's status at the time of discharge. Interviews with facility staff revealed that the Social Services Director (SSD) did not document conversations with the resident about the transfer request or complete a discharge summary. The Minimum Data Set (MDS) nurse noted the discharge order but was not responsible for the discharge process. The Administrator confirmed that the SSD was responsible for providing the discharge summary, which should have been signed by the resident and retained in the medical record. The lack of documentation and discharge summary represents a failure to comply with the facility's Transfer and Discharge Planning policy.
Hazardous Chemicals Found in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident's room was free from hazardous chemicals, which posed a potential health risk. The resident, who has diagnoses of schizoaffective disorder, dementia, and major depressive disorder, was observed to have several hazardous chemicals on the nightstand in their room. These included a half-full can of Raid bug spray, two full cans of Odoban odor spray, and two full spray bottles of Febreeze odor spray. The resident is ambulatory, has full function of their arms, and is moderately cognitively impaired, which could increase the risk of misuse of these chemicals. Observations were made over several days, consistently noting the presence of these chemicals in the resident's room. Interviews with facility staff, including a CNA, an LPN, and the Administrator, revealed that there was an expectation for staff to ensure resident rooms were free from harmful chemicals. However, this expectation was not met, as evidenced by the repeated observations of hazardous chemicals in the resident's room. The staff acknowledged the potential harm these chemicals could pose to residents, indicating a lapse in the facility's supervision and safety protocols.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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