Lebanon North Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Missouri.
- Location
- 596 Morton Road, Lebanon, Missouri 65536
- CMS Provider Number
- 265123
- Inspections on file
- 40
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lebanon North Nursing & Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple mental health diagnoses, who was known to have episodic behavioral outbursts, became upset after a visit to the business office. When the resident refused to return to the unit and began swinging arms, a NA positioned behind the resident and held the resident’s arms and hands up behind the back in an arrest-like manner while walking the resident from the front area back to a special care unit, during which the resident cried continuously. Witness CNAs reported that the BOM walked alongside and attempted to calm the resident but did not intervene to stop the hold. Facility policies required residents to be free from physical restraints unless ordered by a physician for a specific medical symptom, yet there was no restraint order, no care plan for restraint use, and no documentation of the restraint in the medical record. The facility physician later characterized the maneuver as an excessive and unacceptable physical restraint.
A resident with a fibula fracture and ongoing severe pain had repeated gaps in pain management documentation and follow-up. Staff did not update the care plan for pain, did not consistently document whether 1 or 2 tabs of hydrocodone-acetaminophen were given, did not always recheck pain after administration, and did not document physician notification when pain remained unrelieved or when Belbuca was unavailable. The resident reported frequent 8/10 to 10/10 pain, delayed response to the call light, and lack of follow-up after PRN pain meds.
Multiple residents with intact cognition and significant physical care needs reported that certain staff, particularly one NA, were rude, loud, and dismissive, failed to return after agreeing to help, and sometimes told residents to be quiet instead of responding promptly to requests or call lights. One resident described being left in a heavily saturated incontinence brief that had not been changed all day, while CNAs and an LPN confirmed ongoing shortages of briefs and wipes, use of incorrect sizes, and residents sometimes being found soaking wet in the morning. Another resident reported feeling uncomfortable when staff talked over them about personal dating lives during incontinence care, and staff interviews confirmed that such conversations occurred despite expectations not to talk about personal lives or over residents during care. A further resident stated that an NA ignored a request to remake an improperly made bed, and a CNA reported witnessing the same NA inappropriately restrain a resident by holding the resident’s arms behind the back while the resident cried and verbally refused, all of which conflicted with stated expectations that staff respect residents’ dignity, preferences, and rights.
A resident with chronic severe pain, osteoporosis with pathological fracture, and insomnia repeatedly reported that a bed mattress with a pronounced dip caused significant back pain, difficulty positioning, and poor sleep. The care plan required assessing pain’s impact on sleep and positioning for comfort, and the MDS documented almost constant severe pain interfering with daily activities. The resident stated they had informed multiple staff and yelled out at night due to the bed pain. A CNA confirmed the resident’s complaints about a dip in the mattress and noted the mattress could not be flipped. The DON acknowledged the resident slid into a “hole” in the bed and yelled out at night but had not inspected the mattress, and the Administrator was unaware of the issue, despite stating staff could have changed the mattress and should report bed concerns. The facility did not correct the mattress problem, resulting in continued discomfort and an uncomfortable environment for the resident.
The deficiency involves a failure to report an allegation of staff-to-resident abuse involving an unauthorized physical restraint to the state agency. A resident with severe cognitive impairment and multiple mental health diagnoses became upset in the business office and began swinging their arms. A CNA then moved behind the resident, placed the resident’s arms behind their back "like handcuffs," and escorted the resident back to the unit while the resident cried. Other staff, including a CNA and an LPN, witnessed the restraint and recognized it as inappropriate physical contact. Staff interviews confirmed they were trained that physically restraining a resident constitutes a restraint and that any allegation of abuse or neglect must be reported promptly to the DON/Administrator and to the state. Although a CNA reported the incident internally, the DON and another nurse decided on their own that it was not abuse or neglect and did not notify the state, and records review confirmed there was no self-report to the state regarding this allegation.
A resident with severe cognitive impairment and multiple mental health diagnoses, who had a care plan directing calm, non-restrictive behavioral interventions, became upset after a visit to the business office. A nurse aide reported that when the resident began swinging and hitting, the aide restrained the resident from behind with the resident’s arms held behind the back while walking the resident back to the unit, causing the resident to cry; another CNA described the hold as similar to being arrested and stated the resident should not have been taken off the locked unit. Although the facility’s abuse policy requires investigation and measures to prevent further potential abuse, the DON acknowledged that no formal, written investigation of this alleged abuse/restraint incident was completed, and no documented protective steps were provided.
The facility failed to provide pressure ulcer care according to standards of practice for two residents with multiple pressure injuries. One resident was admitted with a left heel eschar and later developed buttock and coccyx wounds, yet weekly skin assessments often documented intact skin, wound assessments were missed, treatment orders were incomplete or not updated to match wound care specialist recommendations, and several ordered treatments were not administered or documented. Another resident with sacral, heel, calf, and foot pressure ulcers had detailed treatment plans from a wound care company, but the POS was not updated to reflect these orders, weekly skin assessments were inconsistent or nonspecific, and treatment records showed missed or incomplete wound care, with incorrect dressings found in place during specialist visits. Across both cases, nursing documentation lacked accurate, timely wound assessments and failed to ensure that current, appropriate orders were followed and recorded.
Failure to honor resident shower preferences and document refusals: two cognitively intact residents who needed bathing assistance were not shown to have received showers at the expected frequency, and care plans did not address bathing preferences. CNA shower review sheets and nurses' notes lacked documentation of showers or refusals, while CNA, LPN, DON, and the Administrator all stated residents should be offered showers at least twice weekly and refusals should be recorded.
A resident with CHF, DM, morbid obesity, and HTN was sent to the hospital after shortness of breath and syncope, but the facility did not document a discharge order, bed hold, transfer notice, or written discharge notice when the resident was not allowed to return. The hospital social worker reported the facility said it would not accept the resident back, while the DON and Administrator stated the resident’s weight and the facility’s lack of equipment/resources prevented readmission.
Failure to Provide and Document Ordered Therapy Services: A resident with falls, weakness, heart failure, and a PT/OT/ST order did not have a documented PT eval or PT participation despite the order and care plan. Another resident admitted with a fibula fracture had a PT order and initial PT assessment, but the care plan was not updated and PT/nursing notes often did not document therapy provided or refused. Staff interviews showed uncertainty about the orders and documentation, and the facility lacked a policy for documenting PT visits.
A resident with severe cognitive and mobility impairments, who was care planned for two-person assistance during personal care, fell from bed and sustained a head laceration and neck fracture when only one staff member was actively providing care. Staff interviews revealed a lack of awareness of the care plan requirements, and the facility lacked a process to ensure staff were informed of each resident's care needs, directly leading to the incident.
A resident with a signed DNR order did not have their code status consistently documented across the EMR, face sheet, and door sticker. Due to delays in updating records, staff initiated CPR when the resident became unresponsive, as available documentation indicated full code status. Staff interviews confirmed that delays and inconsistencies in updating advance directives contributed to the failure to honor the resident's wishes.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident admitted with bilateral groin surgical wounds did not have hospital wound care orders transcribed into the MAR, and staff failed to document wound care or notify the physician in a timely manner about the resident repeatedly removing dressings and changes in wound condition. The care plan was not updated to reflect wound care needs, and there was no evidence of a wound treatment or skin assessment policy being provided. Staff interviews confirmed inconsistent documentation and lack of physician notification regarding wound care issues.
A resident with urinary retention did not have key events documented in their medical record, including physician contact for catheter orders, a catheterization attempt, hospital transfer, and family notification of a change in condition. Staff interviews confirmed that these actions were either not documented or not performed according to facility policy, resulting in incomplete and inaccurate medical records.
Staff were not educated on enhanced barrier precautions (EBP) and did not use required PPE, such as gowns, when providing high-contact care to two residents—one with a urinary catheter and one with a wound. Multiple CNAs and an LPN provided care using only gloves, and staff reported not receiving EBP education or being able to locate gowns. The care plans for these residents did not address EBP, and the facility did not ensure PPE was readily available at the point of care.
A resident who required extensive assistance with bathing did not receive showers or baths as preferred or documented in their care plan, with records showing long periods without showers being offered or completed. Staff interviews revealed there was no designated shower aide or schedule, and showers were provided only once per week due to short staffing, contrary to facility policy and the resident's needs.
A resident with dementia and significant ADL needs did not consistently receive timely showers or bathing assistance, as required by their care plan. Staff interviews revealed the absence of a shower aide, lack of a shower schedule, and short staffing, resulting in showers being provided only about once per week and incomplete documentation of care. The DON acknowledged that resident shower preferences had not been updated and that monitoring was inconsistent.
A resident reported an allegation of sexual abuse to facility staff, but the incident was not reported to the State Survey Agency within the required two-hour timeframe. Despite the resident's distress and the facility's policy mandating immediate reporting, the Administrator and corporate QA Nurse advised waiting for hospital findings, leading to a delay. Interviews with staff confirmed the failure to adhere to reporting protocols.
A deficiency was identified due to the presence of accident hazards and inadequate supervision in a nursing home area. The facility failed to ensure a safe environment, lacking sufficient oversight to prevent accidents, thus compromising resident safety.
A resident with a left leg amputation was not properly secured in a facility van, leading to an injury when they slid out of their wheelchair during transport. The transportation staff failed to fasten the shoulder/lap seat belt due to obstruction by other wheelchairs, despite previous training and warnings. The incident highlighted the absence of a specific policy for resident transport in the facility van.
The facility failed to ensure an RN was on duty for eight consecutive hours on two specific days. The Nurse Monthly Staff Schedule and timecards confirmed the absence of RN coverage. Interviews with the DON, MDSC, and Administrator revealed the facility's non-compliance and difficulties in hiring RNs.
The facility failed to provide an ongoing group or individual activity program to support the physical, mental, and psychosocial well-being of three residents on the secure unit. Staff did not document alternate approaches or one-to-one activities for residents who refused scheduled activities, and there were no scheduled activities or specific resident interactions on the secure unit.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNOC) for two residents, resulting in a deficiency. Both residents did not receive the required NOMNOC or Advanced Beneficiary Notice of Non-coverage (ABN) before the last date of services. Interviews revealed a lack of awareness and understanding of the ABN process among staff, leading to the oversight.
The facility failed to complete a significant change assessment within 14 days for a resident admitted to hospice services. The MDS Coordinator acknowledged the oversight, and the DON confirmed the requirement for timely assessments when there is a significant change in a resident's condition.
The facility failed to refer a resident with new mental disorder diagnoses for a Level II PASARR evaluation. The resident had been diagnosed with anxiety disorder, major depressive disorder, and bipolar disorder, but the facility did not update the PASARR screening or notify the state authority for re-screening.
The facility failed to ensure ongoing pre and post dialysis communication for a resident receiving dialysis three times a week. The review of the resident's Dialysis Transfer Form showed inconsistent completion, and staff did not follow up with the dialysis center to ensure there were no issues. The DON confirmed the importance of ongoing communication before and after dialysis services.
The facility failed to document clinical rationale for PRN psychotropic medication orders longer than 14 days for two residents. One resident had a PRN order for Xanax without proper review or discontinuation, and another resident under hospice care had a PRN order for lorazepam without documented rationale or review.
The facility failed to include a resident's bathing preferences and behaviors in the care plan, despite the resident's known aversion to showers and the calming effect of music. Staff were aware of these preferences but did not communicate them to the MDS Coordinator or document them in the care plan, leading to inconsistent care during bathing.
Unauthorized Physical Restraint Used on Behaviorally Challenging Resident
Penalty
Summary
The deficiency involves staff physically restraining a resident by holding the resident’s arms behind the back while escorting the resident from the business office to the special care unit, contrary to facility policy and without a physician’s order. Facility policies on Resident Rights and Abuse Prevention state that residents have the right to be free from physical restraints except when used to treat a specified medical symptom as part of a total program of care, and that restraints must be authorized in writing by a physician or, in an emergency, by designated professional personnel with immediate notification to the physician. The policies also emphasize that residents must be free from abuse and that physical restraints are prohibited for discipline or staff convenience. In this case, there was no care plan for restraint use, no physician’s order for a physical restraint, and no documentation of restraint use in the resident’s record. The resident involved had diagnoses including bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, with severely impaired cognition per the MDS. The care plan identified socially inappropriate or disruptive behaviors, difficulty understanding others, and disorganized thinking related to mental health issues and intellectual disabilities. Interventions included maintaining a calm environment, avoiding overstimulation, using calm and reassuring approaches, assessing for underlying needs, and allowing the resident to settle when upset. The resident’s progress notes described episodes of behavioral outbursts such as demanding immediate attention for medications or personal needs and occasionally throwing personal belongings, followed by later apologies, but did not include any plan or authorization for physical restraint. On the day of the incident, a nurse aide (NA B) was in the business office with the resident during a Social Security call. After the call, NA B and the Business Office Manager (BOM) attempted to get the resident to return to the unit, but the resident refused and became increasingly upset. NA B reported that outside the business office the resident began swinging arms and hitting NA B on the head, at which point NA B wrapped arms around the resident from behind, placing the resident’s arms behind the mid-back to prevent further hitting, and maintained this hold while walking the resident back to the unit. Multiple CNAs who witnessed the event described NA B holding the resident’s arms and hands behind the back “like being arrested,” with shoulders raised, while the resident cried throughout the walk from the front area to the special care unit. Witnesses stated that the BOM walked beside them and attempted to calm the resident but did not stop the physical hold. The facility physician later stated that staff should not physically restrain residents without appropriate indications, confirmed there was no order for a physical restraint, and characterized the maneuver used by NA B as a physical restraint that was excessive and not acceptable. The resident’s care plan and medical record contained no documentation authorizing or describing the use of this type of physical restraint for behavioral management. The quarterly MDS showed the resident was physically independent in transfers and walking, and there was no indication that a restraint was needed for mobility or safety support. The facility’s DON acknowledged that holding a resident’s hands behind the back “may or may not be considered abuse” and stated that the determination depended on intent and whether marks were left, but also acknowledged that staff had reported the incident as possible abuse. The DON and an LPN decided on their own that the incident did not constitute abuse or restraint and did not conduct an investigation into the allegation, despite staff reports that the resident was upset and crying and that the hold resembled an arrest-type restraint. No documentation was made in the resident’s progress notes about the restraint used when returning from the business office to the special care unit.
Incomplete Pain Management and Documentation
Penalty
Summary
The facility failed to provide a complete and effective pain management program for a resident admitted with a fibula fracture, cardiomyopathy, and obesity. The resident’s admission MDS showed the resident was cognitively intact, independently mobile, and experienced pain that affected sleep. Although the resident had an order for pain assessment every shift and hydrocodone-acetaminophen 5/325 mg, 1 to 2 tablets every 6 hours as needed, the care plan dated 02/09/26 did not address the resident’s pain or pain interventions. Record review showed repeated problems with pain medication administration and documentation. On multiple occasions, staff documented giving hydrocodone-acetaminophen but did not record whether 1 or 2 tablets were administered, and in some entries did not document the resident’s pain level after administration. One progress note documented the resident had constant stabbing and throbbing pain rated 8/10, received hydrocodone-acetaminophen 5/325 mg 1-2 tablets PRN, and reported only some relief, but staff did not document whether one or two tablets were given or notify the physician of unrelieved pain. Similar documentation gaps continued across subsequent days, including entries showing pain levels of 5/10, 7/10, 8/10, 9/10, and 10/10 with repeated PRN opioid administration and limited follow-up documentation. The resident’s pain regimen changed several times, but the care plan was not updated to reflect the resident’s ongoing pain or medication changes. Orders were entered to discontinue hydrocodone-acetaminophen 5/325 mg 1-2 tablets PRN, then to give 2 tablets PRN, then Belbuca 300 mcg every 12 hours, and later Butrans 10 mcg weekly. The MAR showed Belbuca was not administered because it was unavailable, and staff did not document physician notification of the unavailable medication. Later, Butrans was also documented as not administered because it was discontinued, but the physician order sheet and medical record did not document discontinuation of the patch. The resident stated staff often took 30 to 45 minutes to answer the call light, did not ask about pain unless pain medication was requested, did not follow up after medication administration, and did not notify the doctor or family about unrelieved pain.
Failure to Ensure Dignity, Respect, and Adequate Incontinence Care for Multiple Residents
Penalty
Summary
The deficiency involves multiple failures to honor residents’ rights to dignity, respect, self-determination, and appropriate care, particularly related to staff interactions, incontinence care, and response to call lights. Resident #4, who is cognitively intact with significant mobility limitations, pain, osteoporosis with pathological fracture, and urinary incontinence, reported that a nurse aide (NA B) repeatedly failed to return after agreeing to assist and ignored requests for help, including assistance to prepare for scheduled smoking breaks. Resident #4 described NA B yelling down the hall, accusing the resident of “putting things in my mouth,” and characterized NA B as rude, lacking compassion, and potentially aggressive. The resident also reported that another CNA told the resident to be quiet when calling for help, that staff often told the resident to wait and then did not return, and that the only way to get staff attention was to yell. Progress notes documented that the resident frequently yelled and screamed for help if not assisted right away, and Resident Council minutes noted call lights not being responded to on time. Resident #4 further reported significant issues with incontinence care and supplies. The resident stated that staff did not check on or change incontinence briefs for extended periods, leading to a brief that, when weighed with a CNA, was found to weigh about one to 1.3 pounds, and that this was reported to LPNs and the DON, who allegedly responded dismissively. The resident reported being left without appropriate briefs, being out of briefs the prior day, and that staff used briefs that were too big or too small because the facility frequently ran out of the correct size. CNAs corroborated that the facility had ongoing supply shortages of briefs and wipes, that several residents did not have enough briefs, that staff sometimes had to use bariatric or incorrect sizes, and that wipes were unavailable at times, requiring use of wet paper towels and washcloths. One LPN stated that residents may be left soiled at night because some mornings residents were found soaking wet. The DON acknowledged a shortage of briefs, ordering constraints tied to budget, and that staff were instructed to place only a few briefs in rooms at a time. Resident #5, cognitively intact with osteoporosis, anxiety, depression, COPD, and frequent incontinence, reported that NA B was rude and talked over the resident about the aide’s personal dating life while the resident was being changed, making the resident uncomfortable and leading the resident to request that NA B no longer provide care. LPN J confirmed that Resident #5 complained about NA B’s rudeness and that NA B and another CNA had an inappropriate conversation about dating while providing incontinence care. LPN J also reported that residents had complained about NA B being rude, and had personally heard NA B say impatiently in front of the nurse’s desk, “My God, [resident’s name], what do you want now?” Other staff, including a CMT and CNA, stated that staff were expected not to yell at residents, not to talk about personal lives, and not to talk over residents during personal care, indicating that NA B’s conduct was inconsistent with these expectations. Resident #6, cognitively intact with paraplegia, depression, and chronic pain, reported that when the resident asked NA B to remake an improperly made bed, NA B became irritated, walked off to use a phone, did not return to complete the task, and subsequently ignored the resident when passing by. Additionally, CNA D reported witnessing NA B inappropriately restrain another resident (Resident #2) by holding the resident’s arms and hands behind the back “like he/she was being arrested” while walking the resident from the business office manager’s office to the special care unit, during which the resident was upset, crying, and verbally refusing. CNA D stated that other staff witnessed this incident and that it was reported to the DON. Across these events, the administrator and DON both articulated expectations that staff should not tell residents to be quiet, should not yell at or talk over residents, should not ignore residents, and should respect residents’ wishes, but the described staff behaviors and supply failures did not align with those expectations and contributed to the identified deficiency in resident rights and dignity. Additional documentation supports a pattern of delayed response to residents’ needs and disregard for resident comfort and preferences. Progress notes for Resident #4 described frequent yelling for help when assistance was not provided promptly, and staff interviews indicated that some staff told the resident that they were not the only resident needing care and that the resident should not yell because it disturbed others. The DON stated that if a call light was not answered as quickly as the resident wanted, the resident should not be yelling, and that staff encouraged call light use, while Resident Council minutes documented concerns about call lights not being answered timely. For Resident #5, progress notes described the resident as demanding and yelling out “help” after a few minutes when slightly incontinent, and preferring to stay in the room with the door closed, but there was no indication that staff adjusted their approach to address the resident’s expressed discomfort with staff conversations during care. Collectively, the report details multiple instances where staff actions and inactions, including rude and dismissive communication, failure to respond promptly to requests and call lights, inadequate incontinence care, and inappropriate physical handling, failed to uphold residents’ rights to dignity, respect, and appropriate care as outlined in facility policy and resident care plans.
Failure to Address Defective Mattress Causing Ongoing Pain and Discomfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, comfortable, and homelike environment for a resident with chronic severe pain by not addressing a defective mattress that contributed to the resident’s discomfort and difficulty sleeping. The resident, cognitively intact and admitted with diagnoses including right hip pain, left shoulder pain, osteoporosis with pathological fracture, insomnia, and unspecified pain, had a care plan that called for acknowledging pain, assessing its effects on sleep and activity, monitoring non-verbal pain signs, and positioning for comfort. The resident’s MDS documented almost constant severe pain (rated 8/10), frequent interference with day-to-day activities, and occasional sleep disturbance due to pain, with both scheduled and PRN pain medications in use. Progress notes showed the resident yelling for assistance to get into bed. During interviews, the resident repeatedly reported that the bed had a dip or “hole” that caused significant lower back pain, made it difficult to get out of bed, and prevented decent sleep, stating that staff were aware because the resident had told several staff members and yelled out at night due to the pain. A CNA confirmed that the resident complained of hip and back pain and specifically of a dip in the mattress that the resident fell into, and noted the mattress could not be flipped and that the resident had slept in a recliner for a few nights to see if that helped. The DON acknowledged that the resident slid down in bed, yelled out at night about slipping into a hole in the bed, had not personally inspected the mattress, and believed any bed issues should be in the maintenance book, while also stating the resident should have a comfortable mattress. The Administrator reported being unaware of the bed-related pain or nighttime yelling and stated staff could have changed the mattress and should notify nursing or housekeeping if a resident had a bed concern. Despite these reports and the resident’s documented chronic severe pain, the mattress issue was not addressed, resulting in the resident’s ongoing discomfort and inability to rest comfortably.
Failure to Report Alleged Staff Use of Unauthorized Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident abuse in the form of an unauthorized physical restraint to the State Survey Agency (DHSS). The facility’s abuse prevention policy states that residents have the right to be free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms. The policy also emphasizes that restraints are prohibited when used for discipline, convenience, or to unnecessarily inhibit a resident’s freedom of movement. Despite this, an incident occurred involving a resident with multiple mental health diagnoses and severe cognitive impairment, where staff actions constituted a restraint without an order or care plan, and the allegation was not reported to DHSS as required. Resident #2 had diagnoses including bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, with care plan interventions focused on managing socially inappropriate or disruptive behaviors through calm approaches, environmental modifications, reassurance, and communication strategies. The resident’s MDS showed severely impaired cognition but independence with mobility. On the day of the incident, the resident became upset in the business office after a phone call and while receiving printed pictures, escalating into a temper tantrum. According to NA B, when the resident began swinging their arms and hitting the aide on the head, the aide used prior behavioral health training to wrap their arms around the resident from behind, tucking the resident’s arms behind the mid-back and restraining the resident while walking them back to the unit, causing the resident to become upset and cry. Another CNA and an LPN described the resident’s hands being placed behind the back “like handcuffs” or “like being arrested” as the resident cried while being escorted. Multiple staff interviews showed that facility staff understood that physically restraining a resident, including holding arms down or behind the back, constituted a restraint and that any allegation of abuse or neglect, including physical restraint, must be reported immediately to the DON/Administrator and to the state within the required timeframe (one to two hours). CNA E reported the incident to the DON, and the DON acknowledged that aides reported the resident was irate and that NA B was restraining the resident by holding the resident’s arms. The DON and another nurse stated they ruled out abuse and neglect on their own and did not contact the state. Review of facility records and DHSS records confirmed there was no documentation of notification or self-report to DHSS regarding this allegation of abuse in the form of restraint use without an order, without a care plan, and for staff benefit, resulting in the cited deficiency for failure to timely report suspected abuse.
Failure to Investigate and Document Alleged Staff-to-Resident Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of staff-to-resident abuse/restraint was fully and timely investigated and that protective measures were documented and implemented during the investigation. Facility policy on Abuse Prevention, revised 11/28/16, states that residents have the right to be free from abuse, neglect, exploitation, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms, and that the facility must take specific actions in response to alleged violations, including preventing further potential abuse while an investigation is in progress. Despite this policy, the facility did not complete or document a formal investigation after an incident in which a staff member physically restrained a resident. The resident involved had been admitted with diagnoses including Bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, and had a care plan addressing socially inappropriate or disruptive behaviors, difficulty understanding others, and disorganized thinking related to mental health issues. The care plan directed staff to avoid overstimulation, maintain a calm environment and approach, assess whether behaviors endangered the resident or others, and use communication and environmental strategies such as speaking calmly, orienting the resident, and providing comfort measures. The resident’s MDS showed severely impaired cognition but independence with mobility, and progress notes described the resident as alert to self, autistic, occasionally having behavioral episodes when demands were not immediately met, sometimes throwing belongings, and later apologizing. According to staff interviews, a nurse aide (NA B) was with the resident in the business office for a Social Security call, after which the resident refused to return to the unit and became increasingly upset when given printed pictures. NA B reported that outside the business office the resident began swinging arms and hitting NA B on the head, and NA B responded by wrapping arms around the resident from behind, under the resident’s arms, with the resident’s arms tucked behind mid-back, restraining the resident while walking back to the unit, which caused the resident to cry. Another CNA witness stated that the resident should not have been taken off the locked unit, observed NA B yelling at the resident, then getting behind the resident and holding the resident’s arms behind the back “like being arrested,” with the resident crying while being walked in this position, and noted that the BOM walked beside them and attempted to calm the resident. The CNA reported the incident to the DON. The DON later acknowledged that no investigation was completed and that he and an LPN had personally “ruled out” abuse and neglect without a written investigation, and the administrator stated she would have expected a written investigation and that it was the DON’s or her responsibility to determine if it was an abuse situation. No written investigation or documented protective steps were provided for review.
Failure to Provide Accurate Assessment and Consistent Treatment for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in accordance with standards of practice, including timely and accurate skin and wound assessments, appropriate and updated treatment orders, and consistent implementation of ordered treatments for two residents with pressure injuries. For the first resident, admitted with dark, hard eschar on the left heel and a reddened buttock present on admission, the initial wound assessment documented these areas and listed interventions such as pressure-reducing devices, turning and repositioning, and heel protectors. However, the October physician orders did not include any specific treatment for the left heel wound, and the weekly skin assessment dated 10/23 documented intact skin with no issues, contradicting the earlier documentation of a left heel wound. Subsequent weekly skin assessments in November repeatedly documented intact skin with no issues to the feet, despite ongoing references in practitioner notes and other documentation to a left heel wound and buttock/coccyx wounds. For this same resident, staff failed to complete weekly skin assessments on some weeks and did not document ongoing wound assessments for the left heel or coccyx/left buttock wounds in October and November. Nurse practitioner notes on 10/23 and 11/06 described a left heel wound with dry eschar and open areas on the right posterior thigh and left buttock, with plans for specific wound care, low air loss mattress, and wound care consults. Although orders were later entered for buttock and coccyx wound care, a low air loss bed, and wound care consult, the treatment administration records showed missed treatments on multiple dates, and progress notes did not consistently address the status of the wounds. The wound care company’s notes in December documented a large stage 2 coccyx pressure ulcer with specific treatment orders, but the facility’s physician orders did not reflect the use of calcium alginate as described by the wound care company. Additionally, new orders for bilateral heel treatments at the end of December were not carried out on the first two ordered days, and January documentation lacked progress notes regarding the left heel wound despite a dietician note referencing a left heel pressure ulcer. Further, when the wound care company evaluated the resident in early February, they documented an unstageable left heel pressure wound that had been present for several weeks and a new stage 3 pressure ulcer on the right sole, with detailed treatment orders including hypochlorous acid, calcium alginate, Medi honey, bordered foam dressings, and Tubi grips. The facility’s February physician orders, however, were not updated to match these recommendations, instead continuing older orders that omitted calcium alginate, skin protectant, Medi honey, and Tubi grips. Interviews revealed additional concerns: an NA reported finding a dressing on the ball of the resident’s foot dated nearly two weeks earlier, suggesting dressing changes were not occurring as ordered, and the wound care company nurse practitioner stated that both foot wounds were debrided on the initial visit and that staff reported the left heel blister had been present for several months. The second resident had multiple documented pressure ulcers, including a stage 3 sacral ulcer, an unstageable left heel deep tissue injury, a stage 3 left calf wound, and a stage 3 right foot ulcer. The wound care company provided detailed weekly progress notes in December and January, specifying wound measurements, staging, and treatment orders involving cleansing with hypochlorous acid, application of hydrofera blue, hydrogel, super absorbent pads, bordered gauze, and kerlix wraps, with daily dressing changes. Despite these detailed orders, the facility’s physician order sheets in December and January were not updated to reflect the wound care company’s current treatment plans. Instead, the POS continued to list older orders such as cleansing with wound cleanser and applying Santyl with wet-to-dry dressings, and later hydrofera blue combined with wet-to-dry dressings, which did not match the wound care company’s specified regimens. For this resident, weekly skin assessments were incomplete or inconsistent, with at least one week in December lacking a documented skin assessment and other assessments vaguely referencing “existing non-foot skin issues” or foot/ankle issues without specific wound details, even though multiple pressure ulcers were present and being followed by the wound care company. Treatment administration records showed missed or incomplete treatments, including days when ordered treatments to the buttock, left heel, and left lower extremity were not documented as completed, and one instance where staff documented that treatment to the lower left extremity was not done due to running out of time. Wound care company notes on multiple visits also documented that incorrect dressings were in place upon arrival, such as calcium alginate instead of hydrofera blue or the use of wet-to-dry dressings instead of the ordered advanced dressings. Throughout this period, nursing progress notes provided minimal or nonspecific information about the resident’s multiple wounds, despite ongoing changes in wound status and treatment plans documented by the wound care company. Overall, for both residents, the facility failed to ensure that wound care orders from the wound care company were promptly and accurately transcribed into the physician order sheets, failed to consistently perform and document weekly skin and wound assessments, and failed to administer and document wound treatments as ordered. Documentation often conflicted with prior assessments and specialist notes, with wounds being omitted from weekly skin assessments or described only in vague terms. Missed treatments, outdated or incorrect orders, and lack of detailed nursing progress notes regarding wound status contributed to the deficiency in providing appropriate pressure ulcer care and in preventing the development or worsening of pressure ulcers for these residents.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination when staff did not honor reasonable shower preferences for two cognitively intact residents who required assistance with bathing. Resident #4 was admitted with diagnoses including repeated falls, muscle weakness, irregular heartbeat, and heart failure, and the quarterly MDS showed substantial to maximum assistance was needed for bathing, dressing, and mobility. The care plan did not address bathing preferences or assistance level, and the CNA shower review sheets documented only one shower on 03/06/26 and one shower on 04/12/26, with no additional showers or refusals provided. The resident stated he/she had only received six showers since admission, that staff said he/she refused showers even though he/she did not unless it was a holiday or nighttime hours, and that staff did not offer showers two times a week as preferred. Resident #5 was admitted with diagnoses including fibula fracture, cardiomyopathy, and obesity, and the admission MDS showed the resident was cognitively intact and required partial to moderate assistance with bathing. The care plan did not include bathing preferences or assistance level, and no CNA shower review sheets were provided documenting showers or refusals during the resident's stay. Nurses' notes also did not document any bathing refusals. During interviews, CNA D and LPN G were unaware of the resident refusing showers, while both stated residents should be offered two showers per week and refusals should be documented on shower review sheets; the DON and Administrator also stated residents should be offered at least two showers per week and refusals should be documented.
Failure to Provide Proper Discharge Notice and Documented Cause for Non-Return
Penalty
Summary
The facility failed to ensure a resident could remain in the facility unless there was documented cause for transfer and proper discharge notice given. The report states that Resident #3 was sent to the hospital after a change in condition, but the facility did not document a bed hold, transfer notice, discharge notice, discharge order, or written documentation supporting why the resident could not return. The resident’s record also did not show an evaluation for return to the facility after hospitalization. Resident #3’s record showed diagnoses including CHF, DM, morbid obesity, and high blood pressure. The care plan, revised before the event, stated the resident planned to remain in the skilled nursing facility and had no plans to discharge, and staff did not update the care plan to reflect any change in the resident’s desire or need to discharge. Nursing notes documented the resident complained of shortness of breath, had a deep moist cough, briefly passed out, agreed to go to the emergency room, and left by EMS. Later that day, the hospital advised the facility the resident had been admitted, but the facility did not document any discharge process or inability to take the resident back. The hospital social worker later asked whether the facility planned to accept the patient back at discharge. During interviews, the hospital social worker said the facility told the hospital it would not take the resident back and did not give a written discharge notice. Facility staff stated the resident could not return because the resident weighed over 600 pounds and the facility did not have the resources or equipment to care for the resident. The medical record reviewed by surveyors did not show a discharge order on the physician order sheet, written notice of discharge, or documentation that the resident returned to the facility or was evaluated for return.
Failure to Provide and Document Ordered Therapy Services
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were provided as required for two residents. One resident had diagnoses including repeated falls, muscle weakness, irregular heartbeat, and heart failure, and the record showed a hospital discharge order and a physician order for PT/OT/ST evaluation and treatment. Although the care plan indicated ST/PT/OT may evaluate and treat as needed, staff did not document a PT evaluation or PT participation in the progress notes or PT notes during the reviewed period. During interview, the resident stated the facility had previously provided PT but was not offering it after the recent decline, and multiple staff members were unsure whether the resident had a current therapy order or was receiving therapy. A second resident was admitted with a fibula fracture, cardiomyopathy, and obesity, and the admission MDS showed the resident was cognitively intact and independent for mobility. The physician order sheet included PT evaluation and a plan of care for PT five times a week for four weeks, and the PT initial assessment documented decreased balance and strength with a need for therapy to improve function and safety. However, the care plan was not updated to reflect the new PT orders, and the PT notes and nursing notes did not document PT services received or refused on multiple days during the stay, with only one PT note showing services provided before discharge home. Interviews with CNA, LPN, DOR/PTA, DON, and the Administrator showed inconsistent awareness of the therapy orders and documentation expectations. The DOR/PTA stated nursing communicates therapy orders and that therapy notes are completed after each visit, while the DON stated all residents should receive therapy according to physician orders and refusals should be documented in progress notes and therapy notes. The report also noted the facility did not have a policy regarding providing and documenting PT visits.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
Facility staff failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by the fall of a resident during personal care. The resident, who had severe cognitive impairment, impaired mobility, and was dependent on staff for all activities of daily living, was care planned to require two staff for bed mobility and personal care. However, on the day of the incident, only one staff member was actively providing care, while another staff member was present in the room but assisting a different resident. The staff member providing care turned away from the resident to retrieve supplies, during which time the resident rolled out of bed and sustained a head laceration and a neck fracture. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan requirements. The nurse aide providing care was not aware that two staff were required for personal care according to the care plan and typically provided care alone. Other staff members, including CNAs, LPNs, and the DON, confirmed that care should be provided according to the care plan and that two staff should be present and actively participating when indicated. Staff also stated that all necessary supplies should be within reach before starting care, and if additional items are needed, the resident should be safely positioned and not left unattended. Record review showed that the facility did not have a specific policy regarding falls or accidents, and there was no process in place to ensure that staff were consistently aware of and following the care planned needs of each resident. The lack of communication and implementation of the care plan directly contributed to the resident's fall and subsequent injuries. The incident was witnessed, and documentation confirmed the resident's injuries and the sequence of events leading to the fall.
Failure to Honor Resident's DNR Due to Inconsistent Documentation
Penalty
Summary
The facility failed to provide care that reflected a resident's wishes as expressed in their advance directives, specifically a Do Not Resuscitate (DNR) order. Although the resident had a signed DNR order, which was also reflected in the care plan and physician's orders, the code status was inconsistently documented across various sources, including the face sheet, EMR, and the sticker on the resident's door. At the time of the incident, the face sheet and door sticker indicated the resident was a full code, while the DNR order had not yet been uploaded into the EMR due to delays in medical records processing. When the resident experienced respiratory distress and became unresponsive, staff checked the available documentation and, based on the face sheet and door sticker, initiated CPR. Emergency services were called, and CPR was continued by both facility staff and EMS, despite the existence of a signed DNR order that had not been properly communicated or documented in all necessary locations. The resident was ultimately transported to the emergency department after prolonged resuscitation efforts. Interviews with staff revealed that there were known delays in updating and scanning advance directive documents into the EMR, and that staff relied on multiple sources, such as door stickers and face sheets, to determine code status. The medical records staff acknowledged the delay in uploading the DNR order, and other staff members indicated that information about code status was not always consistent or updated in a timely manner, especially for new admissions. This lack of consistent and timely documentation led to the administration of CPR against the resident's documented wishes.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Transcribe and Implement Wound Care Orders and Notify Physician of Changes
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards for a resident admitted with bilateral groin surgical wounds. Upon admission, the resident had orders from the discharging hospital to clean the groin sites daily and to remove Silveron dressings after five days. However, staff did not transcribe these wound care orders into the resident's Medication Administration Record (MAR) or Treatment Administration Record (TAR), and there was no documentation of wound care being completed from admission through several days post-admission. The care plan was not updated to reflect the resident's wound care needs, and there was no evidence of a wound treatment or skin assessment policy being provided by the facility. Throughout the resident's stay, progress notes repeatedly documented that the resident was removing dressings and picking at the incisions, but staff did not notify the physician in a timely manner about the dressings being removed earlier than ordered or about changes in the wound condition, such as the appearance of drainage. Documentation of wound care provided was inconsistent or absent, and staff failed to record completion of wound care or reasons for non-compliance in the MAR or TAR. Communication with the physician regarding the resident's noncompliance and changes in the wounds was not documented until much later, despite ongoing issues. Interviews with facility staff, including CNAs, LPNs, the DON, and the facility physician, confirmed that wound care orders were not entered into the MAR, and that staff did not consistently document wound care or physician notifications. The physician stated that he was not notified about the early removal of dressings or the presence of drainage, and that failure to follow wound care orders could increase the risk of infection. The administrator also confirmed that wound care orders should have been entered and documented appropriately, and that weekly skin assessments and tracking should have been recorded in the electronic health record.
Failure to Document Physician Orders, Catheterization, Hospital Transfer, and Family Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced urinary retention and was subsequently transferred to the hospital. The staff did not document contacting the physician for catheter orders, did not record an attempt to insert a catheter, failed to document the hospital transfer, and did not document notification to the resident's family regarding a change in condition. The facility's own policies required documentation of treatments, intake and output, physician and family notifications, and changes in condition, but these were not followed in this case. The resident in question had a history of chronic obstructive pulmonary disease and benign prostatic hyperplasia, and was moderately impaired, requiring substantial assistance for activities of daily living. The resident reported difficulty urinating, which persisted for several days before any intervention was attempted. Staff interviews revealed that the DON attempted an in and out catheter, which was unsuccessful, and the resident was then sent to the hospital. However, there was no documentation in the medical record of the catheter order, the catheterization attempt, the hospital transfer, or family notification, despite staff stating these actions were taken. Interviews with staff, including the DON and LPNs, confirmed that expected documentation practices were not followed. The DON admitted to failing to enter the physician's orders for the catheter and hospital transfer into the resident's record, and also failed to document family notification. The facility physician did not recall giving a verbal order for the catheter, and there was no evidence of such an order in the records. The lack of documentation was confirmed by review of the resident's progress notes and physician orders, which showed no entries for the events in question.
Failure to Educate Staff and Provide PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a complete and effective infection prevention and control program by not ensuring staff were educated on enhanced barrier precautions (EBP) and by not making appropriate personal protective equipment (PPE) readily available for staff use. Observations revealed that staff did not use gowns when providing high-contact care to residents with indwelling devices or wounds, as required by both CDC guidance and the facility's own policy. Specifically, multiple certified nurse aides (CNAs) and a licensed practical nurse (LPN) provided care to residents with a urinary catheter and a wound, respectively, using only gloves and not gowns during activities such as catheter care, wound care, and incontinent care. One resident with an indwelling urinary catheter was observed receiving care from several CNAs who wore gloves but did not don gowns during high-contact activities, including emptying the catheter bag, transferring the resident, and providing incontinent care. The resident's care plan did not address the catheter or EBP, and the MDS/Care Plan Coordinator confirmed that no care plan was developed for these issues due to competing duties. Another resident with a wound requiring dressing changes was also not care planned for EBP, and staff were unable to locate gowns when preparing for wound care. The LPN performing wound care did not wear a gown, citing lack of availability. Interviews with staff, including CNAs, LPNs, the Director of Nursing (DON), and the Administrator, revealed that staff had not received education on EBP, were unaware of the requirement to wear gowns for residents with catheters or wounds, and often could not find necessary PPE such as gowns. While the DON and Administrator stated that PPE should be available and that staff should be following EBP protocols, direct care staff reported otherwise, and observations confirmed the lack of compliance with EBP requirements.
Failure to Provide Showers According to Resident Preference Due to Staffing and Scheduling Issues
Penalty
Summary
The facility failed to promote and facilitate a resident's right to self-determination by not providing showers or baths according to the resident's preferences and needs. Documentation showed that, for an extended period, staff did not record offering or completing showers for a resident who was dependent on staff for bathing. The resident's care plan required extensive assistance with activities of daily living, including bathing, and specified the need for assistance with showers or baths. Despite this, shower sheets for multiple weeks showed no documentation of showers being offered or completed, both before and after a hospital stay. The resident reported not receiving a shower for two or three weeks prior to hospitalization and expressed that showers were preferable for cleanliness, especially for areas difficult to reach independently. Interviews with staff, including CNAs, the Care Plan Coordinator, and the DON, confirmed that there was no designated shower aide, no shower schedule, and that residents typically received only one shower per week. Staff cited short staffing as a reason for the lack of regular showers and indicated that they did the best they could to provide showers in between other care duties. The DON acknowledged that residents should receive more than one shower or bed bath per week and that shower preferences had not been updated since her tenure began. Facility policy required staff to encourage residents to participate in their own care and to maintain comfort and cleanliness, but these standards were not met for the resident in question.
Failure to Provide Timely Showers and ADL Assistance Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically showering, for a resident with vascular dementia, depression, and pain who resided in the dementia unit. The resident required substantial to maximal assistance with showering and bathing, as well as partial to moderate assistance with toileting and dressing, and was always incontinent of bowel and bladder. Documentation showed that after receiving showers on two consecutive days and refusing one, there was no record of showers being offered or completed for over two weeks in February, and again, no documentation for another two-week period in March. The resident's care plan indicated a need for staff assistance with bathing and hygiene, but this was not consistently provided or documented. Interviews with staff, including CNAs, an LPN, the Care Plan Coordinator, and the DON, revealed that the facility did not have a designated shower aide or a shower schedule. Staff reported being short-staffed and stated that they did the best they could to provide showers, but residents typically only received one shower per week. The DON confirmed that shower preferences had not been completed since her start and that monitoring of completed showers was expected but not consistently documented. These actions and inactions led to the failure to ensure the resident received necessary assistance with ADLs as required.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the State Survey Agency within the required two-hour timeframe. A resident, who was cognitively intact and required assistance with daily activities, reported to facility staff that someone had inserted something into their body while they slept. The resident expressed significant distress and pain, prompting the staff to administer pain medication and arrange for the resident to be sent to the emergency room for evaluation. Despite the resident's clear allegation of sexual abuse, the facility's staff did not report the incident to the Department of Health and Senior Services (DHSS) within the mandated two-hour period. The MDS Coordinator, who was informed of the allegation by a CNA, conducted an assessment and notified the Administrator, the resident's physician, and the corporate Quality Assurance Nurse. However, the Administrator and the corporate QA Nurse advised waiting for the hospital's findings before reporting to DHSS, resulting in a delay in reporting. Interviews with facility staff, including the Administrator, MDS Coordinator, and Director of Nursing, revealed a consensus that the allegation should have been reported immediately. The facility's policy clearly states that any allegations of abuse must be reported to the state agency within two hours if they involve abuse or result in serious bodily injury. The failure to adhere to this policy was acknowledged by the staff involved, who cited miscommunication and reliance on corporate guidance as reasons for the delay.
Accident Hazards and Inadequate Supervision
Penalty
Summary
The report identifies a deficiency related to the presence of accident hazards and inadequate supervision in a nursing home area. The surveyors found that the facility failed to ensure the environment was free from potential accident risks, which could compromise resident safety. Additionally, there was a lack of sufficient supervision to prevent accidents, indicating a lapse in the facility's responsibility to maintain a safe environment for its residents.
Resident Injury Due to Inadequate Securing in Facility Van
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation in the facility's van, leading to an accident. The incident involved a resident with a left leg amputation and other medical conditions, who was dependent on staff for transfers and mobility. During transport back from an event, the resident was not properly secured with a shoulder/lap seat belt due to the obstruction caused by other wheelchairs placed in the van. As a result, the resident slid out of the wheelchair when the van stopped, injuring their knee. The transportation staff, identified as Transportation A and B, did not follow proper procedures for securing the resident in the van. Although the wheelchair was strapped down, the shoulder/lap belt was not fastened because it was obstructed by other wheelchairs. Despite previous training and warnings about the importance of safety restraints, the staff failed to secure the resident adequately, leading to the incident where the resident slid out of the wheelchair and sustained an injury. Interviews with staff and the resident confirmed the sequence of events, highlighting the lack of a specific policy or procedure for transporting residents in the facility van. The facility's internal investigation and employee counseling notices indicated that both transportation staff had been previously warned about safety restraints, yet the deficiency occurred, resulting in the resident's injury.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for eight consecutive hours on two specific days, 05/05/24 and 05/18/24. Review of the facility's Nurse Monthly Staff Schedule for May 2024 confirmed that no RN was scheduled on these dates. Further examination of the timecards for the Administrator, who is also an RN, the Director of Nursing (DON), and another RN corroborated the absence of RN coverage on the specified dates. During interviews, the DON acknowledged the facility's non-compliance with the RN coverage requirement and mentioned that the facility employs only one RN. The Minimum Data Assessment Coordinator (MDSC) also noted difficulties in hiring RNs despite advertising for the positions. The Administrator confirmed the lack of RN coverage on the mentioned dates and highlighted the ongoing challenges in recruiting RNs.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing group or individual activity program to support the physical, mental, and psychosocial well-being of three residents residing on the secure unit. The facility's Activity/Recreational Therapy Manual outlined the need for individualized activity programs and documentation of resident participation, but these protocols were not followed. Specifically, the activity director did not document alternate approaches or one-to-one activities for residents who refused scheduled activities, nor were the residents' strengths and positive aspects identified and discussed as required by the care plan. Resident #15, who had diagnoses including bipolar disorder, anxiety disorder, and Alzheimer's disease, was noted to have refused all activities scheduled on the activity calendar for three consecutive months. Staff did not document any alternate approaches or interventions to engage the resident. Observations showed the resident was alert and personable but was often redirected to his/her room or the TV room without any meaningful engagement. Similarly, Resident #32, with diagnoses including major depressive disorder and moderate dementia, and Resident #44, with diagnoses including senile degeneration of the brain and bipolar disorder, also refused all scheduled activities for three consecutive months. Staff did not document any alternate approaches or one-to-one activities for these residents. Interviews with staff revealed a lack of knowledge and time to provide resident-specific activities, and there were no scheduled activities or specific resident interactions on the secure unit.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure timely provision of a Notice of Medicare Non-Coverage (NOMNOC) for two residents, resulting in a deficiency. Resident #49, admitted with a diagnosis of foot drop, received Medicare Part A skilled services from 03/01/24 to 03/16/24. However, there was no documentation of a NOMNOC or an Advanced Beneficiary Notice of Non-coverage (ABN) provided before the last date of services. During an interview, the resident mentioned that they were not informed about the end of their skilled therapy services or given an option to appeal the decision, which could have potentially improved their condition and reduced pain during transfers. Similarly, Resident #270, admitted with a diagnosis of muscle weakness, received Medicare Part A skilled services from 12/08/23 to 12/13/23, but there was no documentation of a NOMNOC or ABN provided before the last date of services. Interviews with the Business Office Manager (BOM), Administrator, and Social Services Director revealed a lack of awareness and understanding of the ABN process. The BOM stated that NOMNOC forms were issued by the corporate office, but she was unaware of the need to provide an ABN form. The Administrator also confirmed a lack of knowledge about the ABN process, and the Social Services Director mentioned that there was no internal system to track residents being discharged from Part A to ensure timely provision of NOMNOC. The deficiency was attributed to an oversight and lack of communication, as the Social Services Director did not receive the necessary email notifications for the residents in question.
Failure to Complete Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to ensure a significant change assessment was completed within 14 days for a resident who was admitted to hospice services. The Resident Assessment Instrument (RAI) Manual mandates that a Significant Change in Status Assessment (SCSA) must be performed when a terminally ill resident enrolls in a hospice program, with the Assessment Reference Date (ARD) within 14 days from the effective date of the hospice election. Resident #33, who was admitted to hospice services on 08/29/23, did not have a significant change assessment completed within the required timeframe. The resident's quarterly Minimum Data Set (MDS) with an ARD of 02/22/24 did not reflect hospice services received, and the Care Plan dated 05/20/24 showed the resident had chosen hospice services. During an interview, the MDS Coordinator acknowledged that a significant change assessment should have been completed for the resident's hospice admission but was missed. The Director of Nursing (DON) also confirmed that a significant change assessment should be completed within the appropriate timeframe when there is a significant change in a resident's condition. This oversight led to the deficiency noted in the report.
Failure to Update PASARR Screening for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident who had a negative Level I Preadmission Screen and was later diagnosed with a new mental disorder to the appropriate state designated authority for a Level II PASARR evaluation. This deficiency was identified for one resident out of five reviewed for PASARR among a sample of 24 residents. The resident in question was diagnosed with anxiety disorder, major depressive disorder, and bipolar disorder on different dates, but the facility did not update the PASARR screening to reflect these new diagnoses. The resident's significant change Minimum Data Set (MDS) showed moderately impaired cognition, and the initial PASARR screening indicated no signs or history of major mental illness. During an interview, the Social Worker confirmed that the resident's PASARR Level I screen had been completed earlier and did not trigger any mental illness. However, the Social Worker was unaware of the resident's new diagnoses and verified that a Level II PASARR screening had not been conducted. The regulating authority, Missouri Health and Senior Services, had not been notified for a re-screening to be completed.
Failure to Ensure Ongoing Pre and Post Dialysis Communication
Penalty
Summary
The facility failed to ensure ongoing pre and post dialysis communication for a resident receiving dialysis three times a week. The facility's policy required that all care concerns within the last 24 hours be addressed, and that the dialysis unit complete and return a report including weight, labs, medications, follow-up information, and any new physician's orders. However, the review of the resident's Dialysis Transfer Form for March, April, and May 2024 showed that the forms were only completed on four specific dates, indicating a lack of consistent communication between the facility and the dialysis center. During interviews, an LPN mentioned that the dialysis center often did not return the pre and post dialysis forms, and that staff had contacted the resident's guardian to address the issue with the dialysis center. The LPN also stated that staff did not reach out to the dialysis center to ensure there were no issues with dialysis, assuming the center would contact the facility if there were any concerns. The DON confirmed that she had just become aware of the issue and emphasized the importance of having ongoing communication before and after dialysis services.
Lack of Documented Rationale for Extended PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure there was documented clinical rationale for as-needed (PRN) psychotropic medication orders longer than 14 days for two residents. Resident #6, who was admitted with diagnoses including mood disorder and anxiety disorder, had a PRN order for Xanax 0.25 mg for anxiety. The resident's records showed no documented indication for continued clinical use past 14 days, and the pharmacist did not review or recommend discontinuation of the PRN order after the initial 14-day period. The Director of Nursing (DON) acknowledged the oversight and noted that a stop date was later added, but it did not trigger a review by the pharmacist, leading to the continued PRN order without proper documentation. The pharmacist admitted to missing the regulation requirement during monthly medication reviews. Resident #32, admitted with diagnoses including restlessness, agitation, major depressive disorder, moderate dementia, mood disturbance, and anxiety, had a PRN order for lorazepam 0.5 mg every two hours. The resident's records also lacked a documented rationale for continued use past 14 days, and the pharmacist did not review or recommend discontinuation of the PRN order. The pharmacist stated that the resident was under hospice care and did not require the same rationale for PRN lorazepam. The DON noted that the PRN lorazepam order had a stop date set for several months later, which was not initially noticed, leading to the oversight in documentation and review.
Failure to Address Resident's Bathing Preferences and Behaviors in Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident that addressed the resident's bathing preferences and potential behaviors during showers. The resident, who was admitted with multiple diagnoses including a hip fracture, memory loss, anxiety disorder, chronic pain, major depressive disorder, bipolar disorder, and dementia, was cognitively impaired and required assistance with various activities of daily living, including bathing. Despite the resident's known aversion to showers and documented instances of yelling and screaming during showers, these behaviors and preferences were not included in the resident's care plan. Interviews with various staff members, including nurse aides and certified nurse aides, revealed that the resident's dislike for showers and the calming effect of music during showers were known among the staff. However, this information was not communicated to the MDS Coordinator or included in the resident's care plan. Staff members reported using music to calm the resident during showers, but this intervention was not documented in the care plan. The MDS Coordinator and other nursing staff were unaware of the resident's specific behaviors and preferences related to bathing. The facility's policy required the interdisciplinary care plan team to develop and maintain a comprehensive care plan with input from the resident and family, and to revise the care plan as changes occurred in the resident's condition. However, the care plan for this resident did not reflect the resident's bathing preferences or the behavioral interventions used by staff. The lack of communication and documentation led to a failure in providing consistent and appropriate care for the resident during bathing activities.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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