Kirksville Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kirksville, Missouri.
- Location
- 1705 East Laharpe, Kirksville, Missouri 63501
- CMS Provider Number
- 265247
- Inspections on file
- 21
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Kirksville Manor Care Center during CMS and state inspections, most recent first.
Food storage and sanitation standards were not maintained in the kitchen, dry storage areas, and freezers. Staff observed multiple unlabeled, undated, unsealed, and uncovered food items, along with debris, trash, rust, and residue on storage surfaces. A CMT served drinks without hand hygiene and touched cup drinking surfaces with bare hands before serving residents. The ice machine drain was also connected directly to the floor drain with no air gap.
Resident trust funds were mismanaged when one resident's account went negative after store purchases and withdrawals, and two residents had cash amounts over the $50 petty cash limit kept in envelopes in a safe rather than in an interest-bearing account. The SSD said she was responsible for the money in the envelopes and was unaware of the $50 limit, while the Administrator said he handled the trust account but did not know the resident's balance and stated there should be no negative balances.
Resident funds were not properly tracked or reconciled. Several residents had cash stored in envelopes in the SSD office, but the contents were only verified sporadically and not reconciled monthly as required. In addition, the resident trust fund ledger balances did not match the bank account balances over multiple months, and the ADM stated he could not determine the source of extra funds in the account.
Unsafe and Poorly Maintained Resident and Common Areas: Surveyors observed multiple areas of disrepair and poor cleanliness throughout the facility, including damaged room doors, missing floor tile and cove base, holes and cracks in walls, peeling paint, rusted or dusty vents, and dirty or discolored bathroom and shower room floors with missing or cracked caulk around toilets. Staff stated there was no one specifically cleaning floors, no housekeeping supervisor, and floors had not been stripped in about three years.
Care plans were not kept current for multiple residents. One resident’s dialysis access and arm restrictions were not reflected, another’s transfer status and knee immobilizer orders were outdated, and several others had missing or inaccurate documentation for wounds, ostomy/urostomy care, EBP, smoking status, catheter care, dialysis schedule, and transfer assistance. Surveyors observed care that did not match the written plans, and the Care Plan Coordinator acknowledged the plans were behind and not accurate.
Insulin pen administration was not performed per manufacturer instructions for several residents. A CMT did not prime Lantus, Novolog, or Lispro pens before giving ordered doses to multiple residents, and in one observed Lantus injection the pen was held in place for only 6 seconds instead of the recommended 10 seconds. The DON stated staff needed to prime insulin pens with 2 units and hold the pen on the skin for 6 to 10 seconds.
Staff failed to follow EBP during high-contact care for residents with PEG tubes, catheters, dialysis access, and wounds, with CNAs providing incontinence care, transfers, dressing, and bathing prep without gowns. Staff also used a multi-resident glucometer without cleaning it between uses or placing it on a barrier, and CMTs attached insulin pen needles without wiping the pen hubs first. The facility also had no formal Legionella water management team or regular meetings.
A resident with severely impaired cognition, dysphagia, and a feeding tube had decreased alertness, low O2 sat on NC, and abnormal lab results including elevated BUN, Na, Cl, BUN/Cr ratio, and WBC. Staff did not document notifying the MD about the change in condition or the low O2 sat, and the lab results were only faxed later. The resident's rep later contacted the MD, who ordered hospital transfer for evaluation and treatment; hospital records showed acute hypoxic respiratory failure, sepsis, hypernatremia, and dehydration.
The facility failed to provide a bed hold policy and written transfer notice when three residents were sent to the hospital. One resident had low O2 saturation and an elevated RR before EMS transfer, another was hospitalized for dehydration, sepsis, and failure to thrive, and a third was sent out for suspected infection. The medical record lacked documentation that the residents’ representatives received the required notices, and the representatives said they did not receive them. Staff said the transfer packet was supposed to include these documents, but they were not always completed, and the DON said the initiating nurse was responsible for issuing them.
Failure to complete SCSA for two residents after major declines in ADLs, continence, mobility, and wound status. One resident declined after a hip fracture and later developed wounds, required a Hoyer lift, and became dependent for multiple care areas. Another resident worsened from partial/moderate assistance to substantial/max assistance and then to dependence for hygiene, dressing, transfers, bed mobility, and ambulation, with new PT/OT and worsening bladder incontinence. The MDS Coordinator acknowledged one resident should have had a significant change assessment, and the DON stated staff were to follow the RAI process.
Surveyors identified unsanitary conditions in the kitchen, including buildup of debris, dried substances on surfaces, improper storage of cleaning rags, and rust on storage carts. Staff interviews revealed inconsistent cleaning practices and failure to follow established sanitation protocols, leading to unclean kitchen and dining areas.
A resident with cognitive impairment and behavioral issues was physically struck on the thigh by a CNA during care after the CNA believed the resident intentionally disconnected a feeding tube. Multiple staff confirmed the CNA also referred to the resident as a 'pedophile' in the resident's presence, constituting both physical and verbal abuse.
A resident with a history of stroke and on anticoagulant medication experienced a fall from a wheelchair, resulting in severe pain and shortness of breath. Despite ongoing complaints and a family member's request for re-evaluation, the physician was not notified for over 10 hours. The resident was later diagnosed with a hemothorax and multiple fractures in the ER.
A resident at risk for falls sustained severe injuries after a fall in the facility. The facility failed to develop a care plan with fall prevention interventions, complete a thorough post-fall assessment, or notify the DON. The fall was not communicated to the oncoming shift or the on-call physician, delaying evaluation and treatment.
The facility did not maintain resident dignity and self-determination for four residents by failing to provide necessary grooming assistance, such as basic haircuts. This issue was identified through observation and interviews, highlighting a lack of support for residents' personal grooming needs.
The facility failed to provide adequate assistance with ADLs for three residents. Staff did not check for incontinence, and a resident's hair was not groomed or pulled back during meals. Another resident did not receive routine showers, impacting their hygiene and comfort.
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed incontinence care, lack of routine showers, slow response to call lights, and inadequate assistance with meals. The facility's census was 51 residents.
A resident on anticoagulant medication fell from a wheelchair and experienced severe pain, but the facility failed to notify the physician of the resident's condition and medication use. Despite ongoing pain and shortness of breath, the resident was not sent for evaluation until the next day, resulting in the discovery of multiple serious injuries. The facility's failure to follow protocols and communicate effectively led to a significant delay in appropriate medical intervention.
A resident with a history of falls and significant health conditions fell from their wheelchair, sustaining serious injuries due to the facility's failure to implement a fall prevention care plan and conduct a thorough post-fall assessment. Staff did not communicate the fall effectively, delaying evaluation and treatment.
The facility failed to treat residents with dignity and respect, as staff made demeaning comments, ignored call lights, and did not promptly assist incontinent residents. A resident reported a staff member's comment about taxes paying for their stay, and another resident was left in a wet state without immediate care. Additionally, a CNA discouraged call light use, upsetting a resident. The administration was unaware of these issues, highlighting a communication breakdown.
The facility failed to provide adequate assistance with ADLs for four residents, leading to deficiencies in care. A resident was observed without glasses during meals, making it difficult to eat, and was left with wet hair after bathing. Another resident was not repositioned or checked for incontinence as required. Staff interviews revealed that incontinence care was often delayed due to workload, despite the care plans indicating the need for regular checks and assistance.
The facility failed to provide adequate nursing staff, resulting in residents not receiving timely incontinence care, showers, or meal assistance. Observations showed residents left in soiled briefs, missing meals, and not receiving scheduled showers. Staff interviews highlighted the challenges of managing care for residents requiring mechanical lifts, with administration attributing issues to inefficient work practices rather than staffing shortages.
The facility failed to accurately review and update its facility-wide assessment, leading to incorrect documentation of residents' needs for assistance with activities of daily living. The new Administrator, unfamiliar with the process, completed the assessment without the required involvement of the Quality Assurance Team or other disciplines, resulting in discrepancies in the reported number of residents needing assistance with toileting and transfers.
The facility failed to post required COVID-19 precaution signage at the entrance and outside a COVID-19 positive resident's room, violating their infection control policy. Despite the resident being in isolation, there was no signage to inform staff or visitors of necessary precautions. Interviews revealed that staff were informed of the positive test, but signage was not posted due to oversight and workload issues.
The facility failed to accurately assess and timely report changes in a resident's condition following a fall, leading to significant swelling, severe pain, and a wound on the knee. Despite the resident's worsening condition and need for narcotic pain medication and antibiotics, the physician was not timely notified, resulting in a hospital admission for urgent evaluation and treatment.
The facility failed to evaluate, implement, and modify interventions to reduce fall risks for a resident, leading to multiple falls and injuries. Additionally, the resident was not safely secured during transport, resulting in further injury. The facility did not conduct necessary evaluations or update the care plan to address fall risks.
Food Storage, Hand Hygiene, and Ice Machine Drain Issues
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During the kitchen and dietary storage tour, staff were observed with multiple food storage and sanitation issues, including bulk flour, sugar, and salt containers with food debris and sticky residue on the exterior surfaces, refrigerated foods that were not labeled or dated, uncovered bowls of frosted cake, a package of butter that was not securely sealed, an unsealed box of sausage patties, and a large bag of dry noodles that was not sealed. In the dry storage room, a soiled apron was placed on top of an open box of gravy mix packets, uncovered coffee filters were stored near a dusty air conditioner, and food debris, trash, dirt, and an oil-saturated cardboard box were present on the floor and under storage shelves. Additional observations showed similar storage problems in other areas of the facility. In a freezer in the service hall, inner bags in boxes of breaded [NAME], cookie dough, and broccoli were not sealed. In the dietary storage room, a large bag of navy beans was not sealed and food debris and trash were scattered across the floor, including under the food storage shelves. Four upright freezers in the vacant dining room contained food items with labeling and sealing problems, and the freezer shelves and doors showed rust, chipped areas, reddish-brown residue, scratches, and food debris. The Dietary Manager stated he expected food to be stored under sanitary conditions, labeled, dated, and sealed, and said there had been a lot of new dietary staff that made it difficult to implement the deep clean schedule. The facility also failed to ensure proper hand hygiene and safe handling when serving drinks. A CMT served coffee and tea to residents without performing hand hygiene and used bare hands to touch the drinking surfaces of cups before filling and serving them. The CMT acknowledged touching the drinking surfaces and not washing hands or using hand sanitizer when serving drinks. The ice machine was also observed with drain piping connected directly to the floor drain with no air gap present. The Maintenance Supervisor stated he expected the ice machine to have an air gap at the drain to prevent potential backflow into the unit, and the Dietary Manager said he was unaware there was no air gap to prevent backflow of liquid back into the machine.
Resident Trust Funds Mismanaged
Penalty
Summary
The facility failed to implement policies and procedures to ensure resident trust accounts were not allowed to go into a negative balance and failed to deposit residents' personal funds in excess of $50.00 into an interest-bearing account for two residents. The facility reported holding funds for nine residents, but the list of residents with money in the resident trust fund account did not include two residents whose cash was later observed in envelopes kept in a safe in the Social Services Director's office. One envelope labeled with one resident's name contained $66.00 in cash, and another labeled with a second resident's name contained $72.68 in cash. The Social Services Director said she was responsible for the safe keeping and maintenance of the residents' money in the envelopes and was unaware there was a $50.00 limit in petty cash. Resident #53's resident fund ledger showed multiple transactions that caused the account to go negative. After a store purchase and withdrawal, the account balance became -$33.85, and after another purchase and withdrawal, the balance became -$10.82. The resident's guardian said he or she sent the resident $30.00 per month for spending, that Resident #53 was having a hard time managing his or her money, and that extra money had to be sent after one of the resident's purchases. The Administrator said he took over maintenance of the resident trust fund account in July 2025, authorized the resident's purchase in January, was out of the building a lot and did not know if he knew the resident's balance, and stated there should be no negative balances in the resident trust fund.
Resident Funds Not Reconciled or Properly Accounted For
Penalty
Summary
The facility failed to properly hold, secure, and manage residents’ personal money that was deposited with the nursing home. Review of the facility policy showed that the business office was to maintain records of all financial transactions involving residents’ personal funds and that individual accounting ledgers were to be maintained in accordance with generally accepted accounting principles. However, the facility’s resident trust fund ledger list did not include several residents who had money in the trust fund account, including Residents #15, #2, #3, #12, #31, and #38. Observation of envelopes kept in the Social Services Department office showed cash or change stored for multiple residents, including $66.00 for Resident #15, $72.68 for Resident #2, $16.00 for Resident #3, $50.00 for Resident #12, $30.00 for Resident #31, $50.00 for Resident #38, $50.00 for Resident #13, $15.00 for Resident #44, and $0.67 for Resident #48. Each envelope had a prior staff verification of contents, but there was no monthly reconciliation or documentation of monthly verification after the dates noted on the envelopes. The Social Services Director stated she was responsible for the safe keeping and maintenance of the money in the envelopes and was unaware the money was considered petty cash that needed monthly reconciliation. Review of the Resident Trust Fund ledgers, bank statements, and reconciliation forms for three months showed that the total resident trust fund ledger balances did not match the bank account balances. On 12/31/25, the ledgers totaled $7,004.24 while the bank account totaled $12,662.58; on 01/31/26, the ledgers totaled $4,270.64 while the bank account totaled $9,694.12; and on 02/28/26, the ledgers totaled $5,129.14 while the bank account totaled $10,478.95. The Administrator stated he took over maintenance of the resident trust fund account in July 2025, was responsible for monthly reconciliation, and believed there was approximately $2,000.00 extra in the account that had been there since before 2022, but he could not determine where it came from. He also stated the resident cash in envelopes was not reconciled monthly, only when a resident withdrew or deposited money.
Unsafe and Poorly Maintained Resident and Common Areas
Penalty
Summary
The facility failed to maintain resident rooms, bathrooms, shower rooms, and common areas in clean and good repair. During the Life Safety Code tour, surveyors observed multiple deficiencies including missing wooden slats from closet doors, chipped and damaged room doors, missing pieces of floor tile and cove base, holes and cracks in walls, peeling or flaking paint, discolored flooring, rust on vents and heaters, and heavy dust or cobweb accumulation on ceiling vents. Several bathrooms and shower rooms also had missing or cracked caulk around toilets, brown or black residue around toilet bases, dirty or discolored floors, and damaged or loose fixtures. Additional observations in occupied resident rooms showed large holes in walls behind beds, marred walls, peeled paint near an air conditioning unit, and floors with brown, black, or gray discoloration. One room had no mattress on the bed next to the window. In another area, the main dining room ceiling had loose flaking paint, brown discoloration, and a vent with moderate dust accumulation. The Victorian dining room ceiling was not flush and drooped down, with brown discolored areas and cracked, flaking paint. The north and south shower rooms also had dirty floors, missing or cracked caulk, rusted vent areas, scuffed walls, and heavy dust or cobwebs on vents. During interviews, the Housekeeper said the facility did not have someone who specifically cleaned floors, although housekeeping staff mopped daily and did not strip floors. The Maintenance Supervisor said he was the only maintenance staff for the building, there was no housekeeping supervisor, the main dining room ceiling vent was cleaned twice per year in spring and fall, floors had not been stripped in about three years, and staff told him verbally when repairs were needed. The Administrator said he expected residents to have a safe and homelike environment and stated the facility had been without a housekeeping supervisor for approximately one and one-half to two years.
Care plans not updated to reflect current resident care needs
Penalty
Summary
The facility failed to keep comprehensive care plans updated to reflect current care needs for six residents. In a review of 18 sampled residents, surveyors found that the care plans for Residents #1, #34, #22, #45, #6, and #42 did not match current orders, assessments, or observed care. The report states that the comprehensive care plan must be an interdisciplinary communication tool, include measurable objectives and time frames, describe the services to be furnished, and be reviewed and revised periodically. For Resident #1, the care plan still referenced a fistula in the left arm and daily dressing changes, but the resident’s current records and observation showed he/she had a Permacath in the right upper chest for dialysis. The resident’s March 2026 orders included no blood pressure, IV access, or labs in the right arm and no lifting over 15 pounds, but these restrictions were not reflected in the care plan. The Care Plan Coordinator stated the plan should have been updated to show the Permacath and the right-arm restrictions. For Resident #34, the care plan continued to show assistance from one staff and a wheeled walker for transfers, ambulation, toileting, and dressing, while the quarterly MDS showed substantial to maximum assistance for multiple transfers. Orders also showed a right knee immobilizer, non-weight bearing bilateral lower extremities, later transition to weight bearing as tolerated with the immobilizer, and not to use the immobilizer when ambulating. Observation showed the resident being transferred by mechanical lift while wearing the immobilizer, but the care plan did not reflect these current needs. The Care Plan Coordinator said the plan should have included the mechanical lift, knee immobilizer, non-weight bearing status, and related weight-bearing instructions. For Resident #22, the admission MDS, hospital records, physician orders, smoking assessment, and wound-related documentation showed multiple current conditions, including pressure injuries, a foot infection, diabetic foot ulcers, an ostomy, urostomy drainage care, diabetic shoes, enhanced barrier precautions, and tobacco use. However, the care plan last revised on 03/16/26 did not document wounds, the urostomy, diabetic shoes, enhanced barrier precautions related to the urostomy and wounds, or smoking. For Resident #45, the care plan did not match the resident’s current status of a stage 4 pressure ulcer, wound care needs, dependence for transfers, Hoyer lift use, and in-house acquired osteomyelitis and chronic device-related pressure injury; it also continued to reference a wound vac even though no wound vac order was present and observation showed none attached. For Resident #6, the care plan identified a suprapubic catheter, but the resident’s MDS and orders showed a urinary catheter and enhanced barrier precautions every shift for the suprapubic catheter; observation showed the catheter bag hanging from the wheelchair and CNA O emptying it without gown or face shield. For Resident #42, the care plan still listed dialysis on Tuesday, Thursday, and Saturday, while current orders showed dialysis on Monday, Wednesday, and Friday and a Permacath to the right chest, with no care plan update for the dialysis schedule or enhanced barrier precautions related to the Permacath. The Care Plan Coordinator stated that wounds should be included in care plans, care plans should be accurate and reflect direct care needs, and that care plans had not been updated as they should have.
Insulin Pen Administration Not Per Manufacturer Instructions
Penalty
Summary
The facility failed to ensure residents received insulin according to manufacturer instructions when staff did not prime insulin pens before administration and, in one instance, did not hold the pen in place for the full recommended time. The deficiency involved Resident #26, Resident #32, Resident #12, and Resident #8, all of whom received insulin by pen from staff who did not perform the required priming step before giving the medication. Resident #26 had an order for Lantus 10 units subcutaneously each morning. During observation, a CMT attached a needle to the Lantus pen, did not prime it, dialed up 10 units, administered the insulin into the resident’s left upper arm, and held the needle in place for six seconds rather than the 10 seconds directed by the manufacturer. Resident #32 had an order for Novolog sliding scale insulin; when the resident’s blood sugar was 163, a CMT attached a needle to the Novolog pen, did not prime it, dialed up one unit, and administered the insulin into the resident’s left arm. Resident #12 had Novolog sliding scale orders and received insulin on two observed occasions. When the resident’s blood sugar was 210, a CMT attached a needle to the Novolog pen, did not prime it, dialed up four units, and administered the insulin into the resident’s right lower abdomen. On another occasion, when the resident’s blood sugar was 193, the same CMT again attached a needle, did not prime the pen, dialed up two units, and administered the insulin into the resident’s left lower abdomen. Resident #8 had Lispro Kwik Pen sliding scale orders, and during observation a CMT attached a needle, did not prime the pen, dialed up two units, and administered the insulin into the resident’s left upper arm. In interview, the CMT stated he/she did not prime the needle before administering insulin to Residents #32, #12, or #26 and believed priming was only needed when the pen was first opened; another CMT stated he/she thought the pen had been primed before giving Resident #8’s insulin. The DON stated staff needed to prime insulin pens with two units and hold the pen on the resident’s skin for 6 to 10 seconds, and that staff should follow manufacturer guidelines.
Infection Control Failures During Resident Care and Medication Handling
Penalty
Summary
The facility failed to follow infection control standards for multiple residents during personal care, blood glucose monitoring, insulin administration, and Legionella water management oversight. Residents involved included individuals with feeding tubes, suprapubic or other urinary catheters, dialysis access, chronic wounds, pressure ulcers, and diabetes. The report states that staff did not consistently wear gowns and other PPE during high-contact care for residents on enhanced barrier precautions, did not clean a multi-resident use glucometer after use or place it on a barrier during finger sticks, did not clean insulin pen hubs before attaching needles, and did not have a Legionella water management team or regular meetings. For residents on enhanced barrier precautions, staff entered rooms and provided incontinence care, transfers, dressing, bathing preparation, toileting assistance, and other personal care without wearing gowns as required by the posted signs and available PPE. One resident had a PEG tube, bowel and bladder incontinence, and required extensive assistance with transfers and ADLs; staff provided incontinence care and transfers without gowns on multiple occasions. Another resident had osteomyelitis and stage 4 and unstageable pressure ulcers; staff transferred the resident, placed a Hoyer sling, and provided incontinence care without gowns. A resident with a suprapubic catheter and another with dialysis access and a permacath also had staff provide personal care without the required PPE, and staff interviews showed confusion about when gowns were required. The report also describes blood glucose monitoring and insulin administration failures for residents with diabetes. A CMT used a multi-resident glucometer in resident rooms, placed it directly on bedding or bedside tables without a barrier, did not clean the device after use, and then carried it to another resident. The same CMT and another CMT removed insulin pens from the medication cart and attached needles without wiping the pen hubs or rubber seals with alcohol first. The report further states that the facility had no water management team and no regular Legionella water management meetings, and the Administrator, Maintenance Director, and Infection Preventionist confirmed that no formal team or meetings were in place.
Failure to Notify Physician of Abnormal Labs and Change in Condition
Penalty
Summary
The facility failed to notify the physician for one resident when there was a change in condition and abnormal lab results. The resident had severely impaired cognition, difficulty swallowing, and a feeding tube. Progress notes showed the resident was not very alert during a shift, the resident's representative requested labs, and lab orders were obtained and collected. The resident's vital signs showed an oxygen saturation of 87% while on oxygen via nasal cannula, but there was no documentation of the resident's condition and no documentation that staff notified the physician of the low oxygen saturation. The lab results, reported to the facility after collection, showed abnormal values including BUN 38, sodium 159, chloride 121, BUN/creatinine ratio 47.5, and WBC 15.7. A handwritten note on the lab results indicated nursing staff faxed the results to the physician the next day, but the progress notes contained no documentation related to the resident's condition or physician notification at the time the results were received. Later that day, the resident's representative visited, reviewed the labs, and contacted the physician with concerns that the resident was dehydrated, had rapid weight loss, and increased fatigue. The physician ordered transfer to the hospital for evaluation and treatment due to the recent lab results, dehydration, and rapid weight loss. Hospital records showed the resident was admitted with acute hypoxic respiratory failure secondary to pneumonia, sepsis secondary to multifocal pneumonia, hypernatremia secondary to dehydration, metabolic encephalopathy secondary to sepsis, electrolyte derangements, and moderate to severe dehydration with hypernatremia. The DON stated staff were to call physicians with abnormal lab results an hour after faxing them and that the nurse should have contacted the physician when the abnormal labs were noted.
Failure to Provide Bed Hold Policy and Transfer Notice
Penalty
Summary
The facility failed to provide residents and/or their representatives with a copy of the bed hold policy and a written notice of transfer when Residents #2, #4, and #56 were transferred to the hospital. The facility’s Bed Hold Policy stated that residents or representatives are to receive written information about bed-hold policies at least twice, including in the admission packet and at the time of transfer, and that the written notice should explain the bed-hold duration, reserve bed payment policy, facility bed-hold period, per-diem rate if applicable, and return policy. Resident #2 had a responsible party and was sent to the emergency room after a progress note documented oxygen saturation of 87% and a respiratory rate in the high 20s. Resident #4 had a responsible party and was transferred and admitted to the hospital for dehydration, sepsis, and failure to thrive. Resident #56 had a responsible party and was sent to the hospital after the wound care nurse thought the resident had an infection. For all three residents, the medical record showed no documentation that the facility provided the bed hold policy or written transfer notice, and each resident’s representative stated they did not receive those documents. Staff interviews indicated the transfer packet was supposed to include the bed hold policy and transfer/discharge notice, but these documents were not always completed, and the DON stated the nurse who initiated the transfer was responsible for issuing them.
Failure to Complete Significant Change Assessments for Two Residents
Penalty
Summary
The facility failed to complete significant change in status assessments (SCSA) for two residents after their physical condition declined in more than one area and the changes required interdisciplinary review and/or care plan revision. The report states that the facility did not complete the federally mandated MDS assessment within 14 days after it determined, or should have determined, that a significant change had occurred. For Resident #45, the annual MDS showed partial/moderate assistance with showering, dressing, transfers, and walking, no falls, no wounds, and frequent bladder incontinence. The resident then fell and fractured the right hip, and later records showed worsening function, including substantial/maximum assistance with showering, dressing, sit-to-stand, toilet transfers, and walking no longer occurring. The resident also changed from frequent to always incontinent of bladder, had a joint replacement, and had a surgical wound. The MDS Coordinator stated the resident declined after the hip fracture and later falls and wounds, and acknowledged that a significant change should have been completed in August. For Resident #34, the annual MDS showed occasional bladder incontinence and partial/moderate assistance with personal hygiene, sit-to-stand, transfers, toileting, showering, and walking 10 feet. Later quarterly MDS records showed decline to dependent toileting hygiene, substantial/maximum assistance with transfers and walking, and always incontinent of bladder. A subsequent quarterly MDS showed further decline to dependence for upper and lower body dressing and personal hygiene, worsening bed mobility, and walking 10 feet not attempted due to medical condition, with new PT and OT services. The facility did not complete an SCSA for these declines. The MDS Coordinator stated she did not think a significant change was needed because she recalled only a transfer change, and the DON stated staff were to follow the RAI process when determining whether a resident required a significant change assessment.
Failure to Maintain Sanitary Kitchen Practices and Cleanliness
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen, including dried liquid splashes on the wall near sanitation sinks, a buildup of brown debris on the floor under a sanitation sink, and thick black debris on the baseboard behind the sinks. Additional findings included stained sinks, food particles and liquid splatter on shelving, dried substances on outlet face plates and appliance cords, and a white, dry substance on shelves where clean utensils and trays were stored. Rags used for cleaning dining room tables were stored in a plastic can without being soaked in sanitizing solution, contrary to facility policy. Rust was also present on the sides of a cart used for storing clean items. Interviews with staff revealed inconsistencies in cleaning responsibilities and practices. The night shift was reportedly responsible for sweeping, mopping, and cleaning out the dishwasher food strainer, while dietary staff used cleaning solutions with rags to wipe tables, but the solution and rags were only changed out every evening. The dietary manager and administrator confirmed that cleaning duties were divided among staff, but observations indicated that cleaning and sanitation protocols were not consistently followed, resulting in unsanitary kitchen conditions.
Failure to Protect Resident from Physical and Verbal Abuse by CNA
Penalty
Summary
A resident with moderate cognitive impairment, hemiplegia, and a history of behavioral issues, including sexual and verbal behaviors toward staff, was dependent on staff for all activities of daily living and required extensive assistance. During care, a Certified Nurse Assistant (CNA) became agitated with the resident after the resident's feeding tube opened, resulting in soiling of the bed and the need for additional care. The CNA believed the resident had intentionally disconnected the feeding tube and responded by smacking the resident on the thigh below the buttock. Multiple staff interviews and written statements confirmed that the CNA struck the resident with an open hand during care. Additionally, the same CNA was reported by several staff members to have referred to the resident as a "pedophile" in the resident's presence and in the presence of other staff, which was considered a form of verbal abuse. The resident's next of kin was informed of the incident and reported that the resident nodded affirmatively when asked if anyone had hit them. The facility's abuse policy defined both physical and verbal abuse, including hitting and the use of derogatory terms, as prohibited behaviors. Staff interviews indicated that the CNA had become increasingly hostile and aggressive toward the resident, particularly in response to the resident's behavioral issues. The incident was reported internally, and staff statements corroborated the occurrence of both physical and verbal abuse toward the resident.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide appropriate care and treatment following a fall with injury for a resident with a history of stroke and who was on Xarelto, an anticoagulant medication. The resident experienced a fall from a wheelchair and complained of severe right-sided rib pain, rating it 9 out of 10 on the pain scale. Despite the resident's ongoing complaints of pain and shortness of breath, the physician was not notified, and the resident's condition was not re-evaluated by staff until prompted by a family member approximately 2-1/2 hours after the fall. The resident continued to experience significant pain, described as tearful and in distress when repositioned, yet the physician remained uninformed. Approximately 10-3/4 hours after the fall, the resident's pain persisted at a level of 7 out of 10, and the physician was still not notified. Eventually, the resident was sent to the emergency room due to a high blood potassium level, where they were diagnosed with a large right-sided hemothorax, multiple displaced rib fractures, and a right scapular fracture. The on-call physician was initially informed that the resident had slipped from the wheelchair without injury, following facility procedure, but was not updated on the resident's pain, use of anticoagulant medication, shortness of breath, or the fact that the fall was unwitnessed.
Failure to Prevent Falls and Communicate Post-Fall Information
Penalty
Summary
The facility failed to develop a care plan with interventions to prevent falls for a resident who was at risk for falls and had been admitted after experiencing falls at home. The resident sustained a fall while at the facility, resulting in severe injuries including a large right-sided hemothorax, multiple displaced rib fractures, and a right scapular fracture. Staff did not complete a thorough post-fall assessment or notify the Director of Nursing as required by facility policy. Additionally, the fall was not communicated to the oncoming shift at shift change, nor was pertinent information regarding the fall communicated to the on-call physician, who was unfamiliar with the resident, leading to a delay in evaluation and treatment.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to maintain resident dignity and self-determination for four residents by not providing necessary grooming assistance, specifically basic haircuts. This deficiency was identified through observation and interview, indicating that the staff did not adequately support the residents' personal grooming needs. The facility had a census of 51 residents at the time of the survey.
Failure to Assist with ADLs and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents. Staff did not check for incontinence, which is a critical aspect of resident care. Additionally, one resident's hair was not groomed or pulled back from their face during meals and throughout the day, impacting their comfort and dignity. Another resident did not receive routine showers, which is essential for maintaining personal hygiene. These deficiencies were identified through observation, interviews, and record reviews during the survey.
Inadequate Nursing Staff Leads to Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of five sampled residents. This deficiency was observed through the facility's inability to provide timely incontinence care, routine showers for personal hygiene, and prompt responses to call lights. Additionally, the facility did not have adequate staffing to assist residents out of bed for meals and ensure all residents were served meals. The facility had a census of 51 residents at the time of the survey.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide appropriate care and treatment following a fall with injury for a resident with a history of stroke and who was on Xarelto, an anticoagulant medication. The resident experienced a fall from a wheelchair, which was unwitnessed, and complained of severe right-sided rib pain and shortness of breath. Despite these symptoms, the on-call physician was not informed of the resident's pain, the use of anticoagulant medication, or the unwitnessed nature of the fall. The resident's condition worsened, and it was only after a family member's insistence that the resident was re-evaluated and eventually sent to the emergency room, where multiple serious injuries were discovered. The facility's policy on acute condition changes required that significant changes in a resident's condition, such as increased pain, be reported to a physician. However, the nursing staff failed to adequately assess and communicate the resident's condition to the physician. The resident continued to experience severe pain throughout the night, and the physician was not notified of the resident's ongoing pain or the potential complications due to the anticoagulant medication. The lack of thorough post-fall assessment and communication with the physician contributed to the delay in appropriate medical intervention. Interviews with staff revealed that there was a breakdown in communication and adherence to facility policies. The Director of Nursing and the Administrator both expressed expectations that were not met, including the need for thorough assessment and communication of changes in condition. The on-call physician indicated that with complete information, he would have sent the resident for evaluation immediately after the fall. The failure to follow established protocols and communicate critical information resulted in a significant delay in addressing the resident's injuries, which were ultimately severe enough to necessitate hospice care.
Failure to Implement Fall Prevention Measures and Conduct Thorough Post-Fall Assessment
Penalty
Summary
The facility failed to develop a care plan with interventions to prevent falls for a resident who was at risk for falls and had a history of falls prior to admission. The resident, who had bilateral lower extremity amputations and other significant health conditions, was admitted to the facility after a fall at home. Despite being identified as high risk for falls, the resident's care plan did not address fall prevention, and staff did not complete the fall risk evaluation section for interventions. On the day of the incident, the resident fell from their wheelchair and sustained serious injuries, including a large right-sided hemothorax, multiple displaced rib fractures, and a right scapular fracture. The staff failed to conduct a thorough post-fall assessment, did not notify the Director of Nursing, and did not communicate the fall to the oncoming shift or the on-call physician effectively. This lack of communication and assessment delayed the resident's evaluation and treatment, resulting in significant pain and complications. Interviews with staff revealed a lack of awareness regarding the resident's fall history and the absence of fall prevention interventions. The Director of Nursing and other staff members acknowledged that the fall care plan and interventions should have been implemented upon admission. The facility's failure to follow its policies and procedures for fall prevention and post-fall assessment contributed to the resident's injuries and subsequent decline in health.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat four residents with dignity and respect, as evidenced by staff not speaking respectfully to residents and not promptly responding to an incontinent resident requiring assistance. Resident #2, who had severe cognitive impairment and was dependent on staff for various needs, reported that a staff member made a demeaning comment about taxes paying for the resident's stay. Additionally, the resident's call light was turned off by staff without providing the needed assistance. Resident #1, who shared a room with Resident #2, corroborated the incident and expressed dissatisfaction with the staff's response to call lights and the handling of incontinence pads. Resident #12, who also had severe cognitive impairment and was dependent on staff for toileting, was observed standing in the hallway in a wet state. A Certified Medication Technician (CMT) acknowledged the situation but did not address the resident's needs, leaving it to another staff member to provide care later. This lack of immediate response to the resident's needs further exemplifies the facility's failure to uphold dignity and respect. Resident #18, who was cognitively intact but had verbal behaviors and was frequently incontinent, was told by a CNA not to use the call light excessively. This upset the resident, as confirmed by a family member. Staff O reported that CNA E was rude to residents and discouraged them from using the call light, but no action was taken by the administration despite being informed. The Director of Nursing and the Administrator were unaware of these issues, indicating a communication breakdown within the facility.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for four residents, resulting in deficiencies in care. Resident #2, who had severe cognitive impairment and was dependent on staff for various ADLs, was observed without glasses during meals, making it difficult for them to eat properly. Additionally, the resident's hair was left wet after bathing, and they were not repositioned or checked for incontinence as required by their care plan. The resident reported having to yell for a blanket because the call light was out of reach, indicating a lack of attention to their needs. Resident #3, who also had severe cognitive impairment and was dependent on staff for toileting and transfers, was observed sitting in a wheelchair for extended periods without being repositioned or checked for incontinence. Despite the care plan indicating the need for regular checks and assistance, staff interviews revealed that these tasks were not consistently performed due to time constraints and workload. Similarly, Residents #16 and #8, both with severe cognitive impairments and incontinence, were not adequately repositioned or checked for incontinence before meals. Staff interviews confirmed that incontinence care was often delayed until after lunch due to being busy with other residents. The Director of Nursing acknowledged the expectation for routine rounds to include incontinence checks and repositioning but believed there was sufficient staff to meet residents' needs, despite evidence to the contrary.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of several residents who did not receive timely incontinence care, showers, or assistance with meals. Observations and interviews revealed that residents were left in soiled incontinence briefs for extended periods, resulting in skin irritation and discomfort. For instance, one resident was found with a saturated brief and red skin imprints, indicating a lack of timely care. Another resident reported being wet with urine and soiled with feces, with staff confirming that they had not been checked or changed for several hours. The facility's staffing issues also affected residents' ability to receive meals and personal hygiene care. One resident reported missing meals multiple times and waiting hours for assistance with mobility, leading to incontinence episodes. The facility's shower schedule was not adhered to, as evidenced by a resident who did not receive a scheduled shower, resulting in oily and dirty hair. Staff interviews consistently highlighted the challenges of managing care for residents requiring mechanical lifts, which necessitated two staff members, further straining the already limited resources. Interviews with staff, including CNAs and LPNs, consistently pointed to a shortage of staff as the primary reason for the deficiencies in care. Despite the facility's assessment indicating sufficient staffing levels, the reality was that the high number of residents requiring mechanical lifts and extensive care needs overwhelmed the available staff. The facility's administration, however, attributed the issues to inefficient work practices rather than a lack of staff, despite evidence to the contrary. This disconnect between administration and staff perceptions contributed to ongoing care deficiencies, as residents continued to experience delays in receiving necessary care and assistance.
Inaccurate Facility Assessment and Lack of Team Involvement
Penalty
Summary
The facility failed to review and update its facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, last updated on August 1, 2024, was conducted by the Administrator, Director of Nursing (DON), and the Governing Body with the corporation. However, the DON reported having no involvement in completing the assessment, and the Administrator, who was new to the role, admitted unfamiliarity with the process and form. The assessment inaccurately documented that 47 residents were independent with toileting, whereas the DON indicated this was incorrect. Additionally, the assessment understated the number of residents dependent on transfers, with the Administrator acknowledging that the documented number of 13 was incorrect, as 27 residents required mechanical lifts for transfers. Interviews revealed that the Administrator completed the assessment with assistance from the Corporate Administrator but without the required involvement of the Quality Assurance Team or other disciplines. The facility's policy mandates an annual review and update of the facility assessment, involving a team that includes the administrator, medical director, DON, and representatives from various services. The failure to accurately assess and document the residents' needs and the lack of involvement from the necessary team members led to the deficiency in the facility's ability to determine and provide the required resources for resident care.
Failure to Post COVID-19 Precaution Signage
Penalty
Summary
The facility failed to ensure proper signage was posted at the entrance of the building and outside a COVID-19 positive resident's room, which is a violation of their infection prevention and control policy. On observation, there was no signage at the front entrance indicating a COVID-19 outbreak, nor was there any transmission-based precaution signage outside the room of a resident who tested positive for COVID-19. The facility's policy requires visual alerts to be posted to inform staff and visitors of the necessary precautions to prevent the spread of COVID-19. The deficiency involved a resident who was admitted with a fracture of the right femur and later tested positive for COVID-19. Despite the resident being placed in isolation, there was no signage to alert staff or visitors of the precautions needed before entering the room. Interviews with the LPN, Infection Control Nurse, and Director of Nursing revealed that while staff were informed of the positive COVID-19 test, the required signage was not posted due to oversight and workload issues. The Administrator acknowledged the expectation for the facility to adhere to its COVID-19 policy.
Failure to Timely Report Changes in Resident's Condition
Penalty
Summary
The facility failed to accurately assess and timely report changes in condition to the resident's physician for one resident who was admitted following a fall. The day after admission, the resident developed blisters, edema, pain, and bruising to the left knee. Staff did not consistently assess the resident's skin and condition, despite the resident continuing to experience pain requiring narcotic pain medication and receiving antibiotic therapy. The physician was not timely notified of the changes in the resident's condition, leading to a delay in appropriate medical intervention. The resident requested to see their physician 11 days after admission and was subsequently admitted to the hospital with significant swelling from the knee to the toes, severe pain, and a wound on the knee. The facility's policies required prompt notification of the physician for any abnormalities, significant changes in condition, or need to alter medical treatment. However, the facility failed to follow these policies, as evidenced by the lack of documentation and follow-up on the resident's worsening condition. Interviews with staff and review of the resident's medical records revealed multiple instances where the resident's condition was not properly assessed or documented. The facility did not follow up on faxes sent to the physician, and there was no evidence of daily documentation on the resident's blisters and bruising. The resident's condition continued to deteriorate, leading to a hospital admission for urgent evaluation and treatment of a suspected compartment syndrome and infected hematoma.
Failure to Prevent Falls and Ensure Safe Transport
Penalty
Summary
The facility failed to consistently evaluate, implement, and modify interventions to reduce the risk of falls for a resident, leading to multiple incidents of falls and injuries. The resident, who had a history of falls and various diagnoses including altered mental status, muscle weakness, and unsteadiness on feet, was not adequately assessed or provided with a care plan addressing fall risks. Despite multiple falls, the facility did not conduct root cause analyses, update the care plan, or notify the physician and family as required by their policies. The resident experienced several falls within a short period, including incidents where the resident was found on the floor in different locations such as their room and the dining room. These falls resulted in injuries including bruises, skin tears, and reported pain. The facility staff failed to document post-fall evaluations, neurological checks, or any re-evaluation of fall interventions. Additionally, the resident's care plan did not reflect their fall risk or any interventions to prevent future falls. Furthermore, the facility failed to safely secure the resident during transport in the facility van, resulting in the resident sliding out of their wheelchair and onto the floor of the vehicle. This incident was not reported, and no interventions were modified to prevent further falls during transportation. The facility's lack of a policy for securing residents during transport and the staff's inadequate response to the resident's falls and injuries highlight significant deficiencies in the facility's fall prevention and management practices.
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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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