Jefferson City Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson City, Missouri.
- Location
- 1720 Vieth Dr, Jefferson City, Missouri 65109
- CMS Provider Number
- 265285
- Inspections on file
- 27
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Jefferson City Manor Care Center during CMS and state inspections, most recent first.
Facility staff did not complete or properly review the required annual facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. Policy required an interdisciplinary team, including the administrator, governing body representative, medical director, DON, infection preventionist, and multiple department directors, to conduct and annually update this assessment and have it reviewed by the QAA/QAPI team. Record review showed the assessment had not been reviewed by QAA/QAPI for over a year despite an active census, and the administrator acknowledged that no full annual facility assessment had been completed since assuming the role and that the due date for the annual assessment was not known.
Staff failed to follow infection control practices during blood glucose testing for three residents with diabetes. An LPN and a CMT repeatedly placed a shared glucometer and blood sugar supplies directly on medication carts, bedside tables, and a bed without a protective barrier, did not consistently perform hand hygiene between glove changes or after contact with blood, and did not disinfect the multi-use glucometer according to manufacturer instructions, instead wiping it with alcohol pads. Both staff members acknowledged not knowing or not following the manufacturer’s disinfection procedures or the expectation to use a protective barrier, while leadership stated that staff were expected to use proper hand hygiene, place supplies on a clean surface or barrier, and disinfect the glucometer with the designated wipes between residents.
Facility staff did not complete a required baseline care plan within 48 hours of admission for a resident, despite a policy mandating development of a baseline plan of care within that timeframe to address immediate needs. Documentation showed the resident’s baseline care plan was submitted several days after admission. The Administrator confirmed the care plan was late and that it should have been completed within 48 hours, and reported that the full‑time MDS/care plan nurse had been reassigned to floor duties due to short staffing. The MDS Coordinator reported being pulled to work as an RN and experiencing an influx of admissions, which led to falling behind on care plan completion.
Staff failed to develop a comprehensive, person-centered care plan for a resident who was cognitively intact and had diagnoses including anxiety, cardiac arrhythmia, vitamin deficiency, and pain. The only documented care plan focus was smoking, noting that the resident could smoke unsupervised and should avoid injury from unsafe smoking practices, with no care plan entries for ADLs, behaviors, or medical diagnoses. The administrator and MDS Coordinator acknowledged that the care plan should have been more complete and reported that the MDS nurse had been pulled to work as an RN on the floor, contributing to delays and backlogs in care plan development.
Facility staff failed to notify a physician and a resident’s responsible party after an allegation that a CNA slapped the resident on the leg during care. Policy required prompt notification of the physician and resident representative for changes in condition or status, including such incidents. The resident had severe cognitive impairment, non-Alzheimer’s dementia, depression, daily rejection of care, and was always incontinent. Progress notes contained no documentation of any notification, the family member reported learning of the allegation only during a later visit, and the NP confirmed not receiving any call about the incident.
A resident with severe cognitive impairment, dementia, depression, incontinence, and a history of physical aggression during ADLs was slapped multiple times on the leg by a CNA during incontinence care. The facility’s abuse prevention policy required measures to prevent and identify abuse, yet an NA reported hearing forceful smacking sounds from the hallway and observed the CNA striking the resident’s thigh with an open hand several times after the resident hit the CNA. The roommate reported hearing the incident behind a closed curtain, and facility documentation confirmed the allegation was substantiated, although the event was not documented in the resident’s progress notes.
A resident with Alzheimer's Disease and a history of wandering did not have a required wanderguard device in place for an extended period, despite repeated documentation by staff. The device was not replaced or reported to the DON or administrator, and the resident ultimately left the facility unnoticed, returning with an abrasion and without the wanderguard.
Staff failed to document and possibly administer physician-ordered wound treatments for two residents, as evidenced by missing entries on the Treatment Administration Record and resident reports of missed care. The DON and administrator confirmed that documentation was expected for all treatments or refusals, and that missing documentation likely meant treatments were not completed.
A resident with a signed DNR form and care plan indicating DNR did not have their code status consistently documented in all medical records. When the resident was found unresponsive, staff were uncertain of the code status and initiated CPR until the DNR was discovered. Staff interviews revealed a lack of awareness and use of the facility's code status identification systems, leading to the failure to honor the resident's advance directive.
Staff did not consistently provide or document nail care, facial hair grooming, or hair brushing for four residents who required assistance with ADLs. Observations found long nails with debris, untrimmed facial hair, and unkempt hair, despite care plans and facility policy requiring these services. Interviews with CNAs, an LPN, and nursing leadership confirmed the expectation for regular hygiene care, but acknowledged lapses in practice and documentation.
Staff failed to update and implement comprehensive, person-centered care plans for three residents, as required by federal regulations and facility policy. Care plans were not revised in conjunction with quarterly MDS assessments, resulting in outdated documentation that did not reflect current care needs, medication regimens, or required interventions. Interviews with the MDS Coordinator, DON, and Administrator confirmed lapses in care plan updates and ongoing efforts to address the issue.
Facility staff failed to protect residents' medical information, leaving sensitive documents face up on nurse station desks in public areas. Observations showed that report sheets with private details were visible to residents and visitors. Interviews with LPNs and the DON confirmed the breach of protocol, acknowledging that such documents should be covered or turned over to ensure privacy.
Two residents reported missing money and a wallet, but the LTC facility staff failed to report these allegations to the state as required by law. Despite being aware of the incidents, the administrator and other staff members did not fulfill their mandated reporting obligations, citing personal judgment over policy compliance.
A resident with stage three pressure ulcers did not have their wound treatments documented as administered according to physician orders. The resident reported inconsistent dressing changes by the night shift, leading to closely spaced changes by the day shift. The DON acknowledged gaps in documentation and lack of follow-up, while the administrator confirmed that undocumented treatments were assumed not done.
Facility staff failed to ensure safe medication storage and monitoring, as evidenced by an unlocked medication cart left unattended and a resident's medications left out in a community area. A CMT forgot to lock the cart, and a resident's inhaler and nasal spray were left unattended, with multiple residents present. The DON and administrator confirmed that medications should be secured to prevent unauthorized access.
The facility failed to store food properly, leading to potential contamination and outdated use. Observations revealed improperly labeled and dated food items in refrigerators and freezers. The kitchen equipment and surfaces were unsanitary, with grease and food debris accumulation. Additionally, food was served at unsafe temperatures, and ice machines lacked proper drainage, risking cross-contamination. The administrator, acting as dietary manager, acknowledged these issues, noting the kitchen staff's need for training.
The facility did not have an RN on duty for at least eight consecutive hours per day, seven days a week, as required. The absence of RNs on multiple weekends in March, April, and May 2024 was confirmed by the RN staff schedule. The DON was unaware that the eight hours needed to be consecutive, and the Administrator cited staffing shortages as the reason for the gaps, despite ongoing hiring efforts.
Facility staff failed to properly store and label medications, with multiple medication carts containing opened and undated bottles, some of which were expired. Interviews with staff, including a CMT, LPN, DON, and the administrator, revealed a lack of adherence to the facility's medication management policy, which requires checking expiration dates and labeling open dates on multi-dose containers.
Facility staff failed to document collaboration with hospice providers for two residents receiving hospice care, as required by the facility's agreement. Reviews of the hospice binder and medical records showed no coordinated plan of care. Interviews with an LPN, the DON, and the Administrator confirmed the absence of documentation, despite expectations for proper communication and record-keeping.
Failure to Complete and Review Required Annual Facility-Wide Assessment
Penalty
Summary
Facility staff failed to conduct and document an annual facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies, as required by facility policy. The written policy, revised in October 2018, required that once a year, and as needed, a designated interdisciplinary team (including the administrator, a governing body representative, medical director, DON, infection preventionist, and department directors for environmental services, physical operations, dietary, social services, activities, and rehab) conduct a facility-wide assessment to ensure resources were available to meet residents’ specific needs. Record review showed the facility assessment, last updated on 4/7/26, had not been reviewed by the QAA/QAPI team since February 2025, despite a current census of 70. During interview, the administrator stated that he/she had not updated the facility assessment on 4/7/26, had not completed a full annual facility assessment since assuming the role in September 2025, and did not know when the annual assessment was due, estimating it was probably due in February 2026 and acknowledging it was not completed. No specific resident medical histories or conditions were described in relation to this deficiency.
Failure to Follow Hand Hygiene and Glucometer Disinfection Practices During Blood Glucose Testing
Penalty
Summary
Facility staff failed to follow infection prevention and control practices during blood glucose monitoring for three residents with diabetes. The facility’s hand hygiene policy required staff to perform handwashing or use alcohol-based hand rub before and after resident contact and after contact with blood or body fluids, and the glucometer policy required cleaning and disinfection between residents per manufacturer instructions. The manufacturer’s directions specified a multi-step cleaning and disinfection process using appropriate towelettes after each patient use. The facility’s fingerstick glucose policy also required use of clean gloves, cleaning and disinfecting reusable equipment between uses, and handwashing after glove removal, but did not address use of a protective barrier under the glucometer and supplies. For one resident with moderate cognitive impairment and diabetes, an LPN removed the glucometer from the medication cart, placed it directly on the cart without a protective barrier, entered the room without performing hand hygiene, and applied gloves. After checking the resident’s blood sugar, the LPN again placed the glucometer directly on the cart without a barrier, did not sanitize the glucometer, and returned it to the basket with other blood sugar supplies. For another resident with severe cognitive impairment and diabetes, the same LPN placed the glucometer, alcohol pad, and lancet directly on the bedside table without a barrier, attempted a blood sugar check, then removed gloves and donned new gloves without hand hygiene. The LPN placed new supplies on the resident’s bed, used a lancet to obtain blood, used a gloved finger to wipe excess blood from the resident’s finger, removed one glove used to wipe the blood, placed the glucometer on the bed, then picked it up with an ungloved hand, left the room, placed the glucometer directly on the medication cart, handled medications without hand hygiene, and wiped the glucometer with an alcohol pad instead of the disinfectant wipes specified by the facility. For a third resident with intact cognition and diabetes, a CMT exited a resident’s room with the glucometer and placed it directly on the medication cart, inserted a new strip, and laid the alcohol pad and lancet on the cart without a protective barrier. The CMT then entered the resident’s room to obtain the blood sugar, exited, and again placed the glucometer directly on the medication cart without a barrier, wiping it only with an alcohol pad before returning it to the cart. In interviews, the LPN stated he/she used alcohol pads between residents, believed the facility wanted use of purple disinfectant wipes but was afraid to use them without gloves, did not know the manufacturer’s disinfection instructions, and acknowledged missing hand hygiene opportunities and the potential to spread blood-borne illness. The CMT reported using alcohol wipes to sanitize the glucometer, was unaware of the manufacturer’s instructions, and stated he/she had never been trained to use a protective barrier under the glucometer or supplies. The administrator and DON both stated that supplies should be placed on a clean surface or protective barrier, that staff were expected to perform hand hygiene at specified points during blood sugar testing, and that staff were to follow manufacturer instructions and use the purple-tub disinfectant wipes, noting that alcohol wipes were not sufficient to disinfect the glucometer.
Baseline Care Plan Not Completed Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to complete a baseline care plan assessment within 48 hours of admission for one sampled resident, contrary to the facility’s Baseline Care Plan policy revised December 2016, which requires development of a baseline plan of care to meet the resident’s immediate needs within forty‑eight hours of admission. Record review showed the resident’s face sheet documented an admission date, but the corresponding baseline care plan, although reflecting the same admission date, was not submitted until 3/15/26, exceeding the required 48‑hour timeframe. During interviews, the Administrator acknowledged not realizing the baseline care plan was late and confirmed that baseline care plans should be completed within forty‑eight hours, noting that the full‑time MDS and care plan staff member had been pulled to work as a floor nurse due to short staffing. In a separate interview, the MDS Coordinator stated that being reassigned to work as an RN on the floor and an influx of admissions during that period caused them to fall behind on care plans.
Failure to Develop Comprehensive Person-Centered Care Plan for a Resident
Penalty
Summary
Facility staff failed to develop and implement an individualized, comprehensive, person-centered care plan for one resident, as required by facility policy. The facility’s Care Plan Comprehensive Person-Centered Policy, revised December 2016, requires that each resident have a comprehensive care plan with measurable objectives, timeframes, and descriptions of services to meet physical, psychosocial, and functional needs, including resident goals, expressed wishes, and treatment refusals. Surveyor review of the resident’s record showed that the resident had been assessed on the MDS as cognitively intact and diagnosed with anxiety, cardiac arrhythmia, vitamin deficiency, and pain. Despite these identified conditions and needs, the resident’s care plan, last reviewed on 4/7/26, only addressed smoking, stating that the resident is a smoker, can smoke unsupervised, and that the goal is for the resident not to suffer injury from unsafe smoking practices. Record review further showed that the resident’s care plan lacked documentation in all other required care areas, including ADLs, behaviors, and diagnoses, contrary to the facility’s stated care planning process. During interviews, the administrator acknowledged that the resident should have a much more comprehensive care plan than just smoking instructions and reported that the full-time MDS and care plan staff had been pulled to work as a floor nurse due to short staffing. The MDS Coordinator confirmed being pulled to work as an RN on the floor, which caused delays and backlogs in care plan completion, and noted that usual care plan content for most residents includes code status, activities, diagnoses, behaviors, BIMS, Braden assessment, and ADLs, updated quarterly or as needed. These interviews and record reviews demonstrated that the required comprehensive care plan for this resident was not developed beyond the smoking focus.
Failure to Notify Physician and Family After Alleged Staff-to-Resident Abuse
Penalty
Summary
Facility staff failed to notify the physician and the resident’s responsible party after an allegation of staff-to-resident abuse. The facility’s policy on “Change in a Resident’s Condition or Status,” revised February 2021, required prompt notification of the physician and resident representative for changes in the resident’s medical or mental condition and/or status. A certified nursing assistant (CNA) was alleged to have slapped a resident on the leg while providing care. Review of the resident’s progress notes from 1/27/26 to 2/4/26 showed no documentation that the physician or family had been notified of this allegation. The administrator stated that he/she expected the physician and family to be notified when there are allegations of employee-to-resident abuse but could not locate any progress note or incident report documentation showing that such notifications occurred. The resident involved had a Significant Change MDS dated 12/09/25 indicating severe cognitive impairment, daily rejection of care, complete bowel and bladder incontinence, and diagnoses of non-Alzheimer’s dementia and depression. During interview, the resident’s family member reported that facility staff did not notify him/her about the abuse allegation and that he/she only learned of it the following day during a visit, when the administrator asked if he/she knew about the incident. In a separate interview, the nurse practitioner confirmed having no record of, and not receiving, any call from the facility regarding the CNA slapping the resident during care. These findings demonstrate that required notifications to the physician and resident representative were not made or documented following the abuse allegation.
Failure to Prevent Physical Abuse During Provision of Care
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when a CNA slapped the resident on the leg during care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program and Clinical Protocol policy, revised April 2021, stated the facility would develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. An investigation dated 1/28/26 documented that staff notified the administrator that a nurse assistant had witnessed a CNA hit a resident on the leg five times, and witness statements and resident interviews were collected. The investigation concluded the allegation was substantiated. The resident involved had a Significant Change MDS dated 12/09/25 showing severe cognitive impairment, daily rejection of care, and diagnoses including non-Alzheimer’s dementia and depression, with the resident always incontinent of bowel and bladder. The resident’s care plan, dated 04/08/24, identified impaired cognitive function/dementia or impaired thought process, ADL self-care performance deficit, physical aggression, and bowel and bladder incontinence. Progress notes from 1/24/26 to 1/28/26 did not contain documentation that the CNA slapped the resident on the leg while providing care. Interviews provided further detail of the incident. The resident’s roommate reported not seeing the event due to the curtain being closed but stated he/she could hear it. The CNA involved stated that while helping the resident to bed, the resident resisted care, the brief was soaked with urine, and the CNA was working alone; the CNA denied ever hitting or slapping anyone and reported being surprised by the accusation. The administrator reported receiving a call from an RN that a nurse assistant had witnessed the CNA strike the resident five times on the leg while performing pedicare. The nurse assistant witness stated that while walking down the hall, he/she heard a smacking noise, looked into the room, and saw the resident hit the CNA and the CNA hit the resident on the outer part of the left thigh with an open hand, with a total of about five hits or slaps, and noted that although the resident was known to be a “fighter” during care, staff were not supposed to hit residents back.
Failure to Replace Wanderguard Results in Resident Elopement
Penalty
Summary
Facility staff failed to ensure that a resident identified as at risk for elopement consistently had a wanderguard device in place as ordered by the physician. The resident, who had a primary diagnosis of Alzheimer's Disease and a history of wandering and attempted elopements, was assessed as requiring a wanderguard on the left ankle. Despite this, staff documented on multiple occasions over several months that the resident did not have a wanderguard in place, with no documentation of replacement or explanation for its absence. The resident's care plan and physician orders required the wanderguard to be checked every shift and as needed. Progress notes repeatedly indicated the absence of the device, but there was no evidence that staff replaced the wanderguard or communicated the issue to the DON or administrator. Interviews revealed that some staff believed the resident was no longer a safety risk for elopement, while others did not follow up on the missing device, and the DON and administrator were not made aware of the ongoing issue until after the resident left the facility. The deficiency culminated when the resident left the facility without staff knowledge and was found by a community member sitting on a curb near the facility. The resident was returned to the facility with an abrasion and was not wearing a wanderguard at the time. Staff interviews confirmed a lack of consistent action to replace the missing device, despite repeated documentation of its absence and the resident's known risk factors.
Failure to Document and Administer Physician-Ordered Wound Treatments
Penalty
Summary
Facility staff failed to maintain professional standards of care by not documenting the administration of wound treatments as directed by physicians for two residents. For one resident, who was cognitively intact and had venous and arterial ulcers, physician orders required daily wound care on both lower legs. However, the Treatment Administration Record (TAR) lacked documentation of treatment or refusal on multiple specified dates. The Director of Nursing (DON) confirmed that refusals should be documented and that nurses are expected to record all treatments or refusals on the TAR. For another resident, also cognitively intact and receiving surgical wound care, physician orders required pin-site care every shift. The TAR did not contain documentation of wound treatment on several dates across two months. The resident reported that staff were not performing treatments every shift as ordered. The DON was unaware of any refusals and expected treatments to be administered as ordered. Interviews with staff and the administrator confirmed that missing documentation on the TAR likely indicated treatments were not completed, and that the DON was responsible for auditing and addressing missing documentation.
Failure to Honor DNR Status Due to Inconsistent Documentation and Staff Awareness
Penalty
Summary
Facility staff failed to obtain and document a timely advance directive for a resident who had elected Do Not Resuscitate (DNR) status. Despite the resident having a signed DNR form and the care plan indicating DNR, the Physician Order Sheet did not contain an order for the resident's code status or advanced directive. When the resident was found unresponsive, staff were uncertain of the code status and initiated CPR until the DNR status was discovered on the resident's facesheet. The code status was not consistently documented across all relevant records. Interviews revealed that code statuses were supposed to be indicated by colored stickers on residents' doors and maintained in a binder at the nurses' station, but staff involved were either unaware of these systems or did not check them before acting. The LPN who initiated CPR was not aware of the resident's code status and was not familiar with the location of the code status documentation. Both the DON and the administrator confirmed the existence of these systems but could not explain why staff failed to follow the resident's wishes.
Failure to Provide Required Hygiene Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate care to meet the hygiene needs of four residents who required assistance with activities of daily living (ADLs), specifically in the areas of nail care, facial hair grooming, and hair brushing. According to the facility's own policy, residents unable to independently perform ADLs should receive necessary support to maintain personal hygiene, including nail and facial hair care. However, review of care plans, shower sheets, and direct observations revealed that staff did not consistently document or provide these services as required. For example, one resident with severe cognitive impairment and another with a contracted hand both had long nails with debris and untrimmed facial hair, despite care plans indicating the need for staff assistance. Another resident, who was cognitively intact but required setup or cleanup help, reported that staff only trimmed nails upon request and sometimes the nails caused pain. A fourth resident, also with severe cognitive impairment, was observed with unkempt hair, long nails with debris, and un-groomed facial hair, and confirmed that staff only occasionally provided grooming assistance. Interviews with CNAs, an LPN, the ADON, and the administrator confirmed that nail care and facial hair assistance were expected on shower days and as needed, and that staff were directed to brush residents' hair in the mornings. Staff acknowledged that failure to provide these services could lead to infection control concerns and was not dignified for residents. Despite these expectations, documentation and observations showed that the required hygiene care was not consistently provided to the affected residents.
Failure to Update and Implement Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by federal regulations and the facility's own policies. Specifically, care plans were not updated in conjunction with the Minimum Data Set (MDS) assessments, which are mandated to occur at least quarterly. For one resident, the care plan was not updated to reflect the most recent MDS assessment, despite significant care needs including cognitive status, use of multiple medications, dependence on staff for mobility and personal care, and use of oxygen therapy. Another resident's care plan was not updated to include activities of daily living (ADL) or specific anticoagulant medication information following an assessment. A third resident's care plan also lacked updates after a quarterly MDS assessment, despite changes in their care needs and medication regimen. Interviews with facility staff, including the MDS Coordinator, Administrator, and DON, confirmed that the responsibility for updating and revising care plans on a quarterly and annual basis was understood, but not consistently executed. The MDS Coordinator acknowledged being new to the position and working to address the backlog of care plan updates. The Administrator and DON both stated that care plans should be reviewed weekly and updated according to guidelines, and noted that additional staff had been hired to assist with this process. Despite these acknowledgments, the care plans for the sampled residents remained outdated, failing to reflect current assessments and interventions necessary to meet individual resident needs.
Failure to Protect Residents' Medical Information
Penalty
Summary
The facility staff failed to protect the privacy of residents' medical information, as observed during a survey. Medical information for six residents was found face up on the nurse station desks, which were located in a public area visible to other residents and visitors. The facility's policy on confidentiality, dated October 2017, mandates that access to residents' personal and medical records be limited to authorized staff and business associates. However, observations on multiple occasions showed that resident report sheets containing sensitive information such as code status, date of birth, allergies, and diagnoses were left unattended and visible to the public. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed an acknowledgment of the breach in protocol. LPNs admitted that the report sheets and physician notes should not have been left face up, and the DON confirmed that staff are expected to keep such documents covered or turned over to protect residents' privacy. The administrator also stated that medical information should not be accessible to the public and should be properly secured. Despite these expectations, the failure to adhere to the facility's confidentiality policy resulted in a violation of residents' privacy rights.
Failure to Report Allegations of Misappropriation
Penalty
Summary
The facility staff failed to report allegations of misappropriation of money for two residents in accordance with State law. The facility's policy on abuse and neglect mandates timely reporting of such incidents to appropriate agencies, but this was not adhered to. Resident #1, who was assessed with moderate cognitive impairment, reported missing money shortly after admission. Despite multiple staff members, including the Maintenance Director, Therapy Director, and Social Services Designee (SSD), being aware of the allegation, it was not reported to the state. The administrator was informed but did not report the incident, believing the resident's inconsistent statements about the amount of money did not warrant it. Resident #5, assessed as cognitively intact, reported a missing wallet on the first night at the facility. The wallet was later found in a locked housekeeping supply closet, wrapped in a paper towel, suggesting it had been hidden. The Maintenance Director and housekeeper discovered the wallet, and it was returned to the resident. Despite the suspicious circumstances, the administrator did not report the incident to the state, as they did not believe it rose to the level of reportable theft. The Director of Nursing (DON) and SSD were aware of the incident but did not ensure it was reported. The facility's failure to report these incidents highlights a significant deficiency in adhering to mandated reporting requirements. The administrator's decision not to report was based on personal judgment rather than policy compliance, and other staff members, despite being mandated reporters, did not fulfill their obligations. This lack of action contravenes the facility's policy and state law, which require timely reporting of suspected abuse, neglect, or theft to appropriate authorities.
Failure to Document Wound Treatment Administration
Penalty
Summary
The facility staff failed to document the provision of physician-ordered wound treatments for a resident with three stage three pressure ulcers. The resident, who was cognitively intact and did not refuse care, had a care plan that required daily application of a wet to dry topical antiseptic dressing to the sacral wound. The physician's order specified that the dressing should be changed twice a day, approximately 12 hours apart. However, the Treatment Administration Record (TAR) showed missing documentation for the dressing changes on specific dates and times, indicating that the treatments may not have been administered as ordered. Interviews revealed that the resident expressed concerns about the night shift's failure to change the dressing or doing so at inappropriate times, leading to closely spaced dressing changes by the day shift. The Director of Nursing (DON), who also served as the facility wound nurse, acknowledged the gaps in the TAR and admitted to not following up adequately on the shift reports or checking the TARs regularly. The administrator confirmed that if the dressing change was not documented, it was assumed not to have been done, and the DON should have investigated the missing documentation.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility staff failed to ensure medications were monitored and stored safely, as evidenced by two separate incidents. In the first incident, an unlocked medication cart was left unattended on the rehabilitation hall, allowing a resident in a wheelchair to pass by it. The Certified Medication Technician (CMT) admitted to forgetting to lock the cart after administering medication and leaving the area to check on showers. Both the Director of Nursing (DON) and the administrator confirmed that the medication cart should have been locked when unattended to prevent residents from accessing medications that are not theirs. In the second incident, a resident's inhaler and nasal spray were left unattended on a table in the community area, with multiple residents present and no staff supervision. The resident mentioned that the CMT was supposed to return for the medications but did not. The Licensed Practical Nurse (LPN) was unaware of the unattended medications and acknowledged that they should not be left out, as residents could mistakenly ingest them. The DON and the administrator reiterated that medications should not be left unattended, even if the resident is alert, to prevent other residents, especially those with memory issues, from accessing them.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to store food properly, leading to potential contamination and outdated use. Observations revealed that the reach-in refrigerator contained items such as a plastic pour container labeled as Italian with a use-by date of 5/20/24 and a container labeled as ham dated 5/12/24. The reach-in freezer had unlabeled and undated bags of breaded meat, sausage dated 5/7/24, fish dated 5/17/24, and taco meat with a use-by date of 6/01. The walk-in freezer contained open and undated bags of beef, a green tube of meat loosely covered with foil, and other items without proper labeling or dating. Additionally, the cooks' prep refrigerator contained tortillas dated 3/17 with a use-by date of 4/19 and unlabeled containers of pancake batter and French toast mix. The facility also failed to maintain kitchen equipment and surfaces in a sanitary manner. Observations showed an accumulation of grease and food debris around the range hood filters, walls near the deep fryer, and the meat slicer. A heavily soiled towel was found under the cooks' prep refrigerator. The facility lacked policies for kitchen cleanliness and equipment cleaning, contributing to these unsanitary conditions. Furthermore, the facility did not ensure food was served at safe temperatures, with scrambled eggs held at 96°F, sausage at 100°F, and gravy at 126°F, all below the recommended 135°F. The ice machines in the main dining and activity rooms lacked an air gap in the drain, risking cross-contamination. The maintenance director was unaware of the air gap requirement and had overlooked filter replacements. The administrator, acting as dietary manager, acknowledged the issues but noted the kitchen staff was new and in need of training.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight hours per day, seven days a week, as required. The facility, with a census of 72, did not have an RN on duty on multiple weekends in March, April, and May 2024. The facility's policies did not include a policy for RN coverage, and the RN staff schedule confirmed the absence of an RN on specific dates. During interviews, the Director of Nursing (DON) acknowledged awareness of the requirement but was unaware that the eight hours needed to be consecutive. The Administrator also recognized the requirement but cited staffing shortages as the reason for the gaps in the schedule, despite efforts to hire additional RNs.
Medication Storage and Labeling Deficiency
Penalty
Summary
Facility staff failed to store and label medications properly, as observed during a survey. The survey revealed that multiple medication carts contained bottles of medications that were opened and undated, including fish oil, acetaminophen, omeprazole, ibuprofen, magnesium oxide, ferrous sulfate, calcium, senna, melatonin, potassium chloride, and milk of magnesia. Some of these medications were also expired, such as a bottle of ferrous sulfate with an expiration date of January 2024 and a bottle of senna with an expiration date of April 2024. The facility's policy requires that the expiration or beyond-use date on the medication label be checked prior to administering and that the date opened be recorded on multi-dose containers. Interviews with facility staff, including a certified medication technician (CMT), a licensed practical nurse (LPN), the Director of Nursing (DON), and the administrator, revealed a lack of adherence to the facility's medication management policy. The CMT admitted to overlooking some medications and had not yet checked the 300 hall cart. The LPN and DON both stated that it is the responsibility of the CMTs to maintain medication carts, including checking for expired medications and ensuring open dates are labeled. The administrator also expected the DON to monitor staff compliance with these procedures. Despite these expectations, the medication carts were found to contain expired medications and bottles without open dates, indicating a failure in the facility's medication management practices.
Lack of Coordinated Care Documentation for Hospice Residents
Penalty
Summary
The facility staff failed to document collaboration of care with hospice providers for the development and implementation of a coordinated plan of care for two residents receiving hospice services. The facility's Nursing Facility Hospice and Respite Care Services Agreement requires that hospice develop a Plan of Care at the time of admission and update it at least every 15 days. However, reviews of the facility's hospice binder and the residents' medical records revealed a lack of documentation of a coordinated plan of care between the facility and the hospice provider for both residents. This deficiency was identified during a survey of the facility, which had a census of 72 residents. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, confirmed the absence of necessary documentation. The LPN indicated that hospice communication should be documented in a binder at the nurse's station, but was unsure why it was missing. The Director of Nursing and the Administrator both expressed expectations for communication and documentation between the hospice provider and the facility, acknowledging that they were unaware of the missing documentation in the residents' medical records.
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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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