Ozark Nursing And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ozark, Missouri.
- Location
- 1486 North Riverside Rd, Ozark, Missouri 65721
- CMS Provider Number
- 265753
- Inspections on file
- 29
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ozark Nursing And Care Center during CMS and state inspections, most recent first.
A cognitively intact resident, dependent on staff for mobility and requiring a Hoyer lift with two-person assistance for transfers, fell from a manual Hoyer lift and sustained facial and head injuries, including a chin laceration and ongoing numbness in the lower face. During a transfer from wheelchair to bed, staff reported difficulty moving the lift, applied a strong push, and the lift tipped, causing the resident to fall from an elevated position. Facility policy required thorough assessment and investigation after falls, but observations and interviews showed inconsistent and unsafe Hoyer practices: staff pulled on the sling to move the lift, questioned correct strap use, positioned the sling above the resident’s head causing poor alignment, and lowered the resident without locking the wheels. Multiple CNAs, CMTs, an LPN, the ADON, and the administrator described expected standards (open legs, locked legs when raising/lowering, two staff with one operating and one guiding), yet at least one CNA reported no specific Hoyer training, staff expressed concerns that facility lifts were unstable or old, and the maintenance director had not yet completed the monthly safety check and had not been informed of any broken lifts. These findings demonstrate that the facility failed to ensure safe mechanical lift operation and adequate supervision, leading to the resident’s fall and injury.
A cognitively intact resident with multiple chronic conditions had a full set of scheduled morning oral medications prepared and signed out on the MAR by a CMT, who then asked an LPN to deliver them. The LPN placed the medications at the bedside at the resident’s request for milk, left to obtain the milk, returned with it, and then left the room without observing the medications being taken, despite facility policy prohibiting leaving medications at bedside without a physician’s order. Later, the resident reported the medications were missing, and a CNA notified the LPN; the resident subsequently found the pills in the bed. In interviews, the resident reported that staff do not stay to observe medication administration, and the CMT, LPN, ADON, and Administrator all confirmed that there was no order to leave medications at bedside and that medications should not have been left unattended, while the CMT had already documented administration on the MAR.
A resident with vascular dementia, diabetes, and moderate cognitive impairment alleged that a CMT hurt the resident’s hand during medication administration, with multiple staff hearing the resident say staff had hurt the hand and caused bruising. Although staff recognized that hitting or hurting a resident’s hand would constitute abuse, the accused CMT was allowed to continue working, including on the same hall, and was not suspended pending investigation. Required steps such as a complete resident assessment, detailed progress note documenting the allegation, notifications to the physician, family, and administration, and a thorough, documented investigation with submission to the state agency were not completed, and the facility could not provide a full investigation report when requested.
A resident with vascular dementia and moderate cognitive impairment alleged that a CMT hurt their hand during medication administration, became upset, and threw water at the staff member. Multiple staff, including an LPN and CNAs, heard or were told that the resident said staff hurt their hand or caused a bruise, and the allegation was reported internally to the ADON and Administrator. The LPN’s progress note documented the resident’s agitation and behavior but omitted the abuse allegation, and the ADON and Administrator assessed the resident’s bruising and obtained differing accounts from the resident about who caused the injury. Although staff acknowledged that hurting a resident’s hand would be abuse and that such allegations must be reported to the state within two hours, the facility did not report this allegation of possible abuse to the State Survey Agency as required by its own policy.
Surveyors found that the facility did not maintain proper documentation or timely destruction of discontinued and expired controlled medications. Numerous medications, including narcotics and other controlled substances, were stored in a locked file cabinet without required accountability sheets or destruction logs. Staff interviews revealed a lack of awareness and participation in the destruction process, and the DON admitted to not following policy due to missing documentation logs. The facility's own policy for dual-nurse destruction and prompt removal of medications was not followed.
A CNA physically and verbally abused a resident with dementia and Parkinson's by forcibly grabbing the resident's arms and cursing at them during an attempt to remove the resident from the dining room. The resident, who was confused and dependent on staff, resisted the CNA's actions, leading to an escalation where both parties exchanged profanities and the CNA used inappropriate physical force. Facility leadership confirmed the CNA's actions were abusive and not in line with policy.
The facility did not consistently post up-to-date daily nurse staffing information in a clear and accessible location. Observations showed outdated or missing staffing sheets, and record review confirmed several dates with no posted forms. Interviews with LPNs, the receptionist, and administrators revealed unclear responsibilities and oversight regarding the completion and posting of these forms, resulting in noncompliance with required staffing information postings.
The facility did not report an allegation of staff-to-resident abuse to DHSS within the required two-hour timeframe after a CNA witnessed another CNA being rough with a resident who was highly dependent on staff. Additionally, the facility failed to report an allegation of misappropriation of personal items from a resident's room within the required twenty-four-hour period. Staff interviews revealed inconsistent knowledge of reporting requirements for abuse and misappropriation.
Staff failed to immediately remove a CNA from resident care after witnessing rough handling of a non-verbal resident with severe disabilities, allowing the CNA to continue working independently. In a separate case, a resident's repeated reports of missing personal items were not investigated by administration, despite facility policy requiring prompt action on such allegations.
The facility failed to ensure proper labeling and dating of food items in the kitchen, leading to potential contamination risks. Observations revealed undated or expired food items, including cottage cheese, mayonnaise, BBQ sauce, and various cheeses and cooked foods. The Dietary Manager confirmed these issues, and the Administrator emphasized the need for adherence to food safety policies to prevent foodborne illnesses among residents.
The facility failed to administer oxygen as ordered for a resident with COPD, setting the oxygen canister at four LPM instead of the prescribed two LPM. Additionally, oxygen supplies for two residents were not stored or dated properly, with apparatuses left undated and not in plastic bags. Staff interviews confirmed these practices were against facility policy.
A resident was found with an inhaler at their bedside without being assessed for self-administration, contrary to the facility's policy. The care plan did not include self-administration, and there was no physician's order. Staff confirmed the resident was not assessed for self-administration, highlighting a deficiency in medication management.
The facility failed to develop and implement care plans for two residents with nicotine dependence and tobacco use. Despite being cognitively intact, these residents did not have smoking addressed in their care plans, contrary to facility policy. Interviews with staff confirmed that smoking should be documented and care planned, but this was not done.
A resident with chronic pain due to multiple sclerosis and lower back pain did not receive effective pain management. The facility failed to keep lidocaine patches in stock, resulting in missed doses, and the resident reported that oxycodone was ineffective. A CMT did not document or reassess the resident's pain after administering oxycodone and failed to report the issue to the nurse. The DON was unaware of the resident's pain complaints.
The facility failed to ensure the DON did not serve as a charge nurse or CNA when the census exceeded 60. The DON worked in these roles on multiple occasions, with the census ranging from 68 to 73. Staff interviews confirmed the DON's additional duties, impacting her ability to complete her designated responsibilities.
The facility failed to provide showers as preferred for four residents due to staffing issues, leading to significant gaps between showers. Residents expressed dissatisfaction with the infrequency of showers, feeling unclean and desiring more regular assistance. Staff interviews confirmed that shower aides were often reassigned due to understaffing, resulting in inconsistent shower schedules and unmet resident needs.
The facility failed to provide adequate pressure ulcer care for three residents by not consistently assessing and documenting weekly skin assessments and wound tracking. A resident acquired a new pressure ulcer that was not documented, and two other residents had incomplete documentation of their skin conditions. The DON admitted to not measuring wounds during certain periods and was unaware of the lack of weekly assessments.
A resident in a special care unit was neglected for over 11 hours, leading to their death. The resident, who had dementia and required assistance, was found unresponsive under their bed with dried blood and emesis. The facility failed to ensure that staff conducted regular checks and walking rounds, as required by policy. Security footage confirmed no staff entered the resident's room during the night shift.
The facility did not maintain a current facility-wide assessment, necessary for determining resources to care for 71 residents during routine and emergency operations. The last review was in April 2023, and the 2024 update was not conducted. The Administrator, responsible for the assessment, acknowledged the oversight, and no policy was provided to guide the assessment process.
Improper Hoyer Lift Operation and Inadequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance with mechanical lifts, resulting in a resident falling from a Hoyer lift and sustaining injuries. The facility’s own fall protocol required immediate physical and neurological assessment, investigation of the incident, physician and responsible party notification, and completion of a fall incident report after any unintentional change in position to the floor. Resident #2, cognitively intact and dependent on staff for toileting, dressing, and mobility, had a care plan requiring use of a Hoyer lift with assistance from two staff for transfers. Despite this, the resident reported that during a transfer from wheelchair to bed using a manual Hoyer lift, the lift became difficult to move across the floor, staff gave it a strong push, and the lift tipped over, landing on the resident. Record review of the facility’s event report documented that two staff applied the Hoyer straps, raised the resident, and moved the lift toward the bed. As the resident’s body neared the edge of the bed, the lift tipped to the left, causing the resident to fall from the highest position, striking the chin and back of the head and sustaining a laceration that required sutures to the chin. The resident later exhibited bruising around both eyes and a healed scar from the bottom lip to the underside of the chin, and reported ongoing decreased sensation and numbness in the lower half of the face, affecting eating and talking. The administrator, who was called to the room immediately after the incident, did not observe any evidence that the lift was broken or malfunctioning and concluded that the lift simply tipped over during use. Interviews with staff revealed inconsistent and unsafe practices in operating Hoyer lifts and a lack of specific training. One CNA present during the incident stated that no one was operating the lift when it tipped; instead, both CNAs were on either side of the resident pulling on the sling to move the lift, at which point it flipped over. Another CNA present stated that on the day of the incident, one CNA was operating and moving the lift toward the bed while the other CNA was on the opposite side of the bed and not guiding the resident or lift. Multiple staff, including CNAs, CMTs, an LPN, the ADON, and the administrator, described the expected standard that Hoyer lift legs must be open, two staff must be present, one staff should operate the lift while the other guides and positions the resident, and the legs should be locked when raising or lowering the resident. However, one CNA reported not receiving specific Hoyer training, and another CNA and other staff expressed concerns that the facility’s manual Hoyer lifts seemed unstable or old, though the maintenance director stated he had not been informed of any broken lifts and had not yet completed the monthly safety check. Observation of a later transfer using a hospice-owned Hoyer showed staff questioning strap color and whether to attach the middle strap, the sling positioned above the resident’s head causing leaning and a crooked neck, and the operator lowering the resident without locking the wheels, further demonstrating improper and inconsistent use of mechanical lifts. Additional interviews showed that staff had differing understandings of whether pulling on the sling could cause a lift to tip, with some acknowledging that pulling on the sling could create a balance concern and cause an accident, while another CNA did not believe that pulling on the sling without someone operating the lift could cause tipping. The medical director reported he did not recall being notified of the incident at the time, though his notes reflected that the facility had reported the lift as broken, and he confirmed awareness of the resident’s ongoing lack of sensation in the lower portion of the face. The maintenance director stated that maintenance was responsible for inspections and repairs of facility-owned Hoyer lifts and that lifts with reported issues would be tagged out of service, but he had not yet performed the monthly safety check and had not received any staff reports of broken lifts. Overall, the observations, interviews, and record review showed that staff were not consistently trained or following safe operating procedures for mechanical lifts, and that the facility failed to ensure safe operation of the Hoyer lift and adequate supervision during transfers, resulting in the resident’s fall and injury.
Medications Left at Bedside and Inaccurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate documentation and safe administration of medications. Facility policy stated that nurses must use acceptable nursing practices when administering medications, never leave medications in a resident’s room without a physician’s order to leave them at bedside, and remain with the resident until medications are taken or remove them if refused. Despite this, staff left a full morning medication pass at a cognitively intact resident’s bedside without a physician’s order and documented the medications as administered on the MAR by a staff member who did not actually give them. The resident involved had multiple diagnoses, including COPD, Parkinson’s disease, type II diabetes mellitus, borderline personality disorder, PTSD, ADHD, bipolar disorder, hypertension, and bladder dysfunction, and had active orders for several scheduled oral medications during the morning med pass, including pantoprazole, Mag 64, ondansetron, a multivitamin, Lipitor, bethanechol, aspirin, and amlodipine. On the date of the incident, a CMT signed these medications out on the MAR but asked an LPN to deliver them. The LPN entered the resident’s room, woke the resident, and informed the resident that the medications were present. When the resident requested milk and stated he or she would take the medications if milk was provided, the LPN left the medications at the bedside, obtained milk, returned, placed a straw in the milk carton, and then left the room without observing the resident take the medications. Later that morning, the resident reported that the morning medications were missing and requested to speak with the Administrator. A CNA responded to the call light and was told by the resident that medications had been delivered while the resident was awake, that the resident then fell asleep, and that upon waking for breakfast the medications were missing. The LPN was notified of the alleged missing medications. A subsequent progress note documented that the resident later located the pills next to him or her and apologized to the LPN. In interviews, the resident stated that staff do not stay to observe medication administration despite being asked, and that on the day in question the LPN initially claimed the medications had been taken until the resident later found them in the bed. The CMT, LPN, ADON, and Administrator all acknowledged in interviews that medications should not be left at the bedside without a physician’s order and that the resident did not have such an order, confirming that facility policy was not followed and that the staff member who signed the MAR was not the one who actually delivered and observed administration of the medications.
Failure to Investigate Abuse Allegation and Remove Accused Staff From Duty
Penalty
Summary
The deficiency involves the facility’s failure to immediately and fully investigate an allegation of staff-to-resident abuse and to protect the resident and other residents during the investigation. The facility’s own Abuse and Neglect Policy required that all reports of resident abuse be thoroughly investigated by administration or designees, that accused employees be placed on leave at the time of the allegation, that the resident and reporter be protected from retaliation, and that findings be documented and reported to the state agency. The policy also required review of documentation and evidence, interviews with the reporter, the resident, staff who had contact with the resident, and at least ten other residents cared for by the accused employee, as well as complete documentation of the investigation and submission of a follow-up report to the state within five working days. Despite these requirements, the facility did not initiate or complete a full, documented investigation and did not remove the accused staff member from duty when an allegation of abuse was made. The resident involved had vascular dementia with moderate cognitive impairment, diabetes mellitus, and hypertension, and required staff assistance with transfers and mobility. The resident frequently rejected care. On the date of the incident, a CMT entered the resident’s room to administer medications, check blood sugar, and give insulin. The CMT reported that the resident became irate after administration, claimed injury to the hand, and began swatting and throwing water. The CMT stated that the resident accused the CMT of hurting the resident’s hand and that this was reported to an LPN and the ADON. The LPN’s written statement indicated the resident was yelling that the CMT had hurt the resident’s hand and that the LPN observed a couple of light bruises on both hands, described as usual, with no new injury noted. Another CNA reported hearing the resident hollering and the resident saying staff hurt the resident’s hand. A different CNA reported that the resident pointed to the CMT and said, “He gave me that bruise,” and this was immediately reported to the ADON and LPN. Despite these direct allegations that staff had hurt the resident’s hand and caused bruising, the accused CMT continued to work after the allegation, including on the same unit and the following day, and was not suspended pending investigation. Facility staffing records confirmed the CMT worked after the allegation. The LPN documented in a progress note that the resident became upset, threw water on the CMT, and was educated about staff being there to help, but did not document the resident’s allegation of possible abuse, any assessment of the resident, or notifications to the physician, family, or administration. The electronic medical record contained no entries related to an abuse assessment or further information about the allegation. The ADON reported assessing the resident and noting old bruising on both hands that did not appear suspicious, but this assessment was not documented in the medical record as a formal skin assessment. The Administrator acknowledged that the CMT was not suspended, that the CMT continued to work on the resident’s hall, and that a progress report with resident statement, notifications, and assessment should have been completed. The facility did not provide a full completed investigation upon request, and state records showed no investigation had been submitted. Subsequent observation documented multiple bruises on both of the resident’s hands, and the resident reported obtaining the bruising when staff helped the resident out of bed. Multiple staff, including the CMT, LPNs, RN, and other CNAs, stated that hitting or hurting a resident’s hand or causing a bruise would be considered abuse and that an allegation of abuse should trigger resident assessment, documentation, and notifications. The ADON and Administrator both described expectations that allegations of abuse be reported promptly to administration and the state, that residents be assessed for bruises or marks, and that progress notes include what happened, assessments, and notifications. However, in this case, those steps were not carried out as required. The facility failed to initiate an immediate, thorough, and documented investigation, failed to suspend the accused employee at the time of the allegation, allowed the accused staff member to continue working independently, and failed to submit an investigation report to the state agency, resulting in noncompliance with the facility’s abuse policy and regulatory requirements for responding to alleged abuse.
Failure to Timely Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two-hour timeframe, as required by facility policy and state law. The facility’s Abuse and Neglect Policy states that suspected abuse must be reported immediately to administration and to the state licensing agency within two hours for allegations of abuse or those resulting in serious bodily injury. On the date in question, a resident with vascular dementia, diabetes mellitus, and hypertension, who had moderate cognitive impairment and frequently rejected care, alleged that a certified medication tech (CMT) hurt his/her hand during medication administration, including a blood sugar check and insulin injection. According to staff statements, the CMT entered the resident’s room to administer medications, check blood sugar, and give insulin. The resident became irate, claimed injury to his/her hand, and began swatting and throwing water at the CMT. The CMT reported to an LPN that the resident accused him/her of hurting the resident’s hand, and the LPN and ADON were informed of the accusation. The LPN documented in a progress note that the resident became upset, threw water, and yelled at staff, but did not document the resident’s allegation that staff caused injury to the hand. Multiple staff, including a CNA, reported hearing the resident hollering and the resident stating that staff hurt his/her hand or gave him/her a bruise, and one CNA reported that the resident pointed at the CMT and said, “He gave me that bruise.” Staff interviewed acknowledged that hitting or hurting a resident’s hand would be considered abuse and that such allegations should be reported to the state within two hours. The ADON and Administrator were made aware of the situation. The ADON stated that his/her understanding was that the resident said the CMT hurt his/her finger during a finger stick, which the resident reportedly says often, and that he/she noted old bruising on the resident’s hands but no new bruising. The Administrator reported being notified that someone hurt the resident’s hand and, upon questioning the resident, was told that a man who got the resident out of bed grabbed the resident’s hand too tightly, while the resident denied that the employee giving medications hurt him/her. The Administrator also noted bruising on the resident’s hands and stomach, which he/she believed related to lab draws and insulin injections. Despite these allegations and assessments, DHSS records showed the facility did not report the allegation of possible abuse on that date, and the Administrator later acknowledged that he/she should have reported and followed policy regarding the initial abuse report. Further observation and interview with the resident showed multiple bruises on both hands, including circular reddish-purple and purple bruises of various sizes, and the resident reported obtaining the bruises when staff helped him/her out of bed. Staff interviews consistently reflected knowledge that abuse allegations must be reported promptly to administration and to the state within two hours. However, the allegation that staff hurt the resident’s hand and caused bruising was not reported to DHSS within the required timeframe, constituting the failure to ensure all allegations of possible abuse were timely reported to the State Survey Agency as required by facility policy and regulation.
Failure to Timely Destroy and Document Discontinued Controlled Medications
Penalty
Summary
The facility failed to maintain an ongoing monitoring process for the documentation, destruction, and accountability of expired or unusable medications, particularly controlled substances. Surveyors observed that a locked file cabinet in the DON/ADON's office contained numerous discontinued and expired medications for approximately 34 residents, including controlled substances such as morphine, lorazepam, temazepam, fentanyl, tramadol, pregabalin, and haloperidol. Many of these medications lacked the required individual narcotic accountability sheets, and some had been retained for several months after residents had expired or been discharged. The facility's own policy required prompt removal and destruction of such medications, with documentation by two licensed nurses, but this was not followed. Interviews with staff, including the ADON, LPNs, the physician, the pharmacist, the DON, and the administrator, revealed a lack of awareness and responsibility regarding the destruction of discontinued medications. The ADON, new to the position, was unaware of the quantity of medications stored and had not participated in any destruction process. LPNs reported that discontinued medications were given to the DON for destruction but had not witnessed any destruction events. The DON admitted to not having destroyed any medications with the ADON and was unable to locate the Drug Destruction Log, resulting in medications being stored indefinitely in the file cabinet. The DON and administrator both acknowledged that the number of discontinued medications on hand was unacceptable and not in line with facility policy. The facility did not provide a logbook documenting the destruction of controlled substances, as required by policy. Observations and interviews confirmed that medications were not destroyed within the expected 30-day timeframe, and there was no evidence of the required dual-nurse destruction process or proper documentation. The physician and pharmacist both stated that medications should be destroyed promptly to prevent diversion, and the facility's failure to do so was attributed to high staff turnover and lack of clear responsibility.
Staff-to-Resident Physical and Verbal Abuse in Dining Room
Penalty
Summary
A certified nurse aide (CNA) physically and verbally abused a resident by grabbing the resident's arm and wrist and cursing at the resident during an incident in the dining room. The resident, who had diagnoses including cancer, nutritional deficiency, dementia with agitation, depression, and Parkinson's disease, was observed to be confused, an elopement risk, and dependent on staff for most activities of daily living. On the day of the incident, the resident was agitated, exit-seeking, and had set off emergency exit door alarms. Staff attempts to redirect the resident were unsuccessful, and the resident struck the CNA in the face during the altercation. Facility video footage and staff interviews confirmed that the CNA repeatedly attempted to physically remove the resident from the dining room by pushing the wheelchair, jerking it, and lifting the front to prevent the resident from stopping movement with their feet. The CNA also pushed the resident's arms abruptly and grabbed at the resident's hands and arms in an attempt to control the resident's movements. During the incident, both the resident and the CNA exchanged profanities, with the CNA responding to the resident's verbal outburst with a curse. The CNA did not seek assistance or attempt to de-escalate the situation by leaving and reapproaching. Interviews with facility leadership and staff acknowledged that the CNA's actions constituted both physical and verbal abuse, as defined by the facility's abuse and neglect policy. The CNA admitted that cursing at or physically redirecting a resident would be considered abuse. Leadership staff, including the ADON and DON, reviewed the incident and agreed that the CNA's handling of the situation was inappropriate and abusive, noting that the resident was permitted to be in the dining room and should not have been forcibly removed.
Failure to Consistently Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post current daily nurse staffing information in a clear and readable format in a prominent location accessible to residents and visitors. Observations over several days revealed that the staffing sheets posted near the front entrance were outdated, with some sheets dating back several weeks, and at times the clipboard intended for posting was empty. Review of records showed multiple dates where no staffing forms were available, indicating gaps in compliance with posting requirements. Interviews with staff, including LPNs, the receptionist, and administrators, revealed confusion and lack of clarity regarding responsibility for completing, posting, and checking the daily nurse staffing forms. While it was generally understood that the night shift nurse was to complete the form at midnight and the DON or administrator was responsible for ensuring completion, the receptionist was not aware that checking the forms was part of their duties. This lack of clear assignment and oversight led to the failure to post current staffing information as required.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. A Certified Nursing Assistant (CNA) witnessed another CNA being rough and aggressive with a resident who had severe intellectual disabilities, epilepsy, and spastic quadriplegic cerebral palsy, and was dependent on staff for all activities of daily living. The incident was reported by the witnessing CNA to the receptionist and then to the nurse, but not immediately. The nurse subsequently notified the former Administrator, who suspended the accused CNA and initiated an investigation. However, the facility did not document reporting the abuse allegation to DHSS until over two hours after the CNA became aware of the potential abuse. Additionally, the facility failed to report an allegation of misappropriation of resident property within the required twenty-four-hour timeframe. A resident, who was cognitively intact and required assistance with activities of daily living, reported multiple personal items missing from their room, including lip balm, sharpies, and stuffed animals. The grievance was reported to the DON, Administrator, and management staff, but was not reported to DHSS as required. The Social Services Designee (SSD) and Administrator confirmed that the report of missing items should have been considered misappropriation and reported to DHSS, but this did not occur. Interviews with staff revealed inconsistent understanding of the required reporting timeframes for abuse and misappropriation. While most staff stated that abuse should be reported to the charge nurse immediately and to DHSS within two hours, there was confusion regarding the timeframe for reporting misappropriation. Some staff were unaware of the specific requirements, and the SSD admitted not knowing how long the facility had to report allegations of misappropriation. The former Administrator acknowledged responsibility for ensuring staff were aware of abuse and neglect policies.
Failure to Protect Residents and Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse and misappropriation involving two residents. In the first incident, a certified nursing assistant (CNA) was observed by another CNA to be handling a non-verbal resident with severe intellectual disabilities and spastic quadriplegic cerebral palsy in a rough and aggressive manner, including yanking the resident's legs and rolling the resident forcefully during care. Despite witnessing this behavior, the reporting CNA did not immediately intervene or report the incident, and the accused CNA continued to provide care to residents independently for several hours before being sent home. The facility's own policy required immediate suspension of any employee accused of abuse and prompt initiation of an investigation, but these steps were not followed in a timely manner, leaving residents unprotected during the interim. The second incident involved a resident with a history of respiratory infection, diabetes, and chronic cough, who reported multiple personal items missing from their room, including lip balm, sharpies, and stuffed animals. The resident stated that these concerns had been reported to the former administrator over the previous two to three months, but no follow-up or investigation was conducted. The grievance was documented, but since the resident did not witness the items being taken or know who was responsible, the matter was not reported to outside agencies, and there was no evidence that an internal investigation was initiated as required by facility policy. Interviews with staff revealed a general understanding of the need to protect residents and initiate investigations in cases of abuse or misappropriation. However, in practice, the required procedures were not consistently followed. The accused CNA was not immediately removed from resident care after the abuse was witnessed, and the allegation of misappropriation was not investigated by the administrator or director of nursing. These failures resulted in the facility not protecting residents from potential harm and not addressing allegations of theft in accordance with established policies.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to ensure that all food stored in the main kitchen was free from possible contamination due to improper labeling and dating of food items. During an observation, several food items in the reach-in refrigerator were found to be either undated or past their use-by dates. These included an opened container of cottage cheese with no date, a gallon of mayonnaise and BBQ sauce with used dates, and various other items such as shredded meat, cheeses, and cooked foods that were either undated or improperly stored. The Dietary Manager confirmed these observations and acknowledged that the items should have been dated correctly with an open date and a use-by date, and that leftovers should only be kept for three days. Further inspection of the walk-in refrigerator revealed a crate of 36 undated thawed Mighty Shakes, which according to the manufacturer's instructions, should be consumed within 10 days after thawing. The Administrator expressed that the expectation was for the dietary staff to follow the policy for labeling and disposing of food appropriately to ensure the residents are served safe and quality food. The failure to adhere to these standards had the potential to increase the prevalence and spread of foodborne illnesses and infections among all 68 facility residents.
Failure to Administer and Store Oxygen Supplies Appropriately
Penalty
Summary
The facility failed to provide respiratory care per standard practice for three residents. For one resident, the staff did not administer oxygen as ordered. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and was at risk for ineffective breathing patterns, was observed using a nasal cannula with the oxygen canister set at four liters per minute (LPM) instead of the prescribed two LPM. This discrepancy was noted over several days, and the Licensed Practical Nurse (LPN) acknowledged signing off on the Medication Administration Record (MAR) without verifying the actual oxygen flow rate. Additionally, the facility did not ensure proper storage and dating of oxygen supplies for two other residents. One resident's updraft apparatus was observed undated and not stored in a plastic bag, contrary to the facility's policy. Another resident's nasal cannula was found draped over a table without a date on the tubing. Both residents had diagnoses related to respiratory issues, including COPD and chronic respiratory failure with hypoxia. Interviews with staff confirmed that oxygen supplies should be stored in a bag and dated, which was not adhered to in these cases.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident who had not been assessed to self-administer medications. Specifically, a resident was observed on multiple occasions with an inhaler lying on the bedside table next to their recliner. The resident's care plan did not include self-administration of medications, and there was no physician's order for self-administration. The facility's policy requires that residents must be alert, oriented, and have a physician's order to self-administer medications, which must be kept in a locked box or drawer. During interviews, an LPN and the Director of Nursing confirmed that the resident had not been assessed to self-administer medications and that the inhaler should not have been in the resident's room. The Nurse Practitioner also stated that no medications should be at a resident's bedside unless they have been assessed to self-administer. This oversight indicates a failure to adhere to the facility's medication administration policy, resulting in a deficiency.
Failure to Care Plan Smoking for Residents
Penalty
Summary
The facility failed to develop and implement a complete care plan for two residents who were identified as smokers. Resident #12, admitted on January 31, 2024, with a diagnosis of nicotine dependence, did not have a care plan addressing their smoking habits. The resident was cognitively intact and reported only smoking when a family member visited. The family member confirmed visiting three times a week to assist the resident with smoking, as the resident could not light or dispose of cigarettes independently. Despite these details, the care plan dated March 21, 2024, did not include any provisions for managing the resident's nicotine dependence or smoking. Similarly, Resident #62, who was admitted with a diagnosis of tobacco use, also lacked a care plan addressing smoking. The resident's significant change MDS indicated no cognitive impairment, yet the care plan dated May 16, 2024, did not include smoking management. Interviews with the Director of Nursing and the MDS Coordinator revealed that smoking should be documented and care planned, but this was not done for Resident #62. The facility's policy required smoking to be discussed during care plan meetings and included in the care plan upon admission, but this was not adhered to for these residents.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain due to multiple sclerosis and lower back pain. The resident had a care plan that required staff to address pain complaints promptly and administer PRN medication for breakthrough pain. However, the facility did not keep the resident's lidocaine patches in stock, resulting in missed doses on three consecutive days. Additionally, the resident reported that the administered oxycodone was no longer effective, but this was not documented or reported to the nurse on duty. During an observation, the resident expressed severe back pain to a Certified Medication Technician (CMT), who acknowledged the lack of lidocaine patches and failed to report the resident's ongoing pain to the nurse. The CMT admitted to not reassessing the resident's pain after administering oxycodone and not documenting the administration on the Medication Administration Report (MAR). The Director of Nursing was unaware of the resident's pain complaints and emphasized the importance of addressing pain promptly and involving the physician if current measures were insufficient.
DON Serving as Charge Nurse and CNA Despite High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse or certified nurse aide (CNA) when the facility census was greater than 60. The facility census was recorded as 68, and on multiple occasions, the DON worked in roles other than her designated position. Specifically, on August 9, 2024, the DON worked as a charge nurse during the evening shift when the census was 72. On August 13, 16, 19, and 23, 2024, the DON worked as a CNA or Licensed Practical Nurse (LPN) during various shifts, with the facility census ranging from 71 to 73. Interviews with facility staff, including the DON, LPN A, and the Minimum Data Set (MDS) Coordinator, confirmed that the DON frequently worked on the floor as a charge nurse or CNA due to staffing needs. The MDS Coordinator noted that the administration staff, including the DON, often worked as nursing staff, which made it difficult for the DON to complete her designated duties. The DON herself acknowledged being behind on her responsibilities due to covering shifts on the floor. The facility did not provide a policy outlining the responsibilities of the DON position, and the Administrator was aware of the DON's additional duties.
Failure to Provide Resident Showers Due to Staffing Issues
Penalty
Summary
The facility failed to uphold residents' rights to self-determination by not providing showers as preferred for four residents out of a sample of 14. The facility's policy outlined a specific shower schedule, but records showed significant gaps between showers for the residents. For instance, one resident received showers with intervals ranging from 7 to 14 days, despite expressing a preference for more frequent showers. Another resident, who was cognitively intact, required assistance with bathing but experienced similar delays, receiving showers with intervals of up to 20 days. Interviews with residents revealed dissatisfaction with the frequency of showers, with some residents feeling unclean and expressing a desire for more regular assistance. The Director of Nursing acknowledged that the residents should have received showers more frequently than they did. The facility's failure to adhere to the shower schedule and provide adequate assistance was attributed to staffing issues, as confirmed by multiple staff members during interviews. Staff interviews highlighted a pattern of understaffing, with shower aides being reassigned to other duties due to staff shortages. This led to inconsistent shower schedules and unmet resident needs. The Director of Nursing and the Administrator both recognized the issue, noting that there was no designated staff for showers and that residents were not receiving showers as frequently as expected. The deficiency was primarily due to inadequate staffing, which prevented the facility from fulfilling its obligation to support resident choice and self-determination in personal care routines.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. The staff did not consistently assess and document complete, thorough, and accurate weekly skin assessments, nor did they complete weekly wound tracking for the residents with pressure ulcers. The facility's policy required weekly skin assessments and documentation by the charge nurse, including size, description, color, odor, and any change in skin condition, but these were not adhered to. For Resident #1, the facility did not document the presence of a new pressure ulcer acquired on 07/29/24, nor did they provide a description or measurements of the ulcer in the weekly skin assessments. The resident's progress notes and medication records from 07/29/24 through 09/08/24 showed a lack of documentation regarding the pressure ulcer. The DON admitted to not measuring the resident's wounds from 07/29/24 through 08/26/24 and was unaware of the lack of weekly skin assessments. Resident #2 was readmitted with moisture-associated skin damage (MASD) on 07/07/24, but staff failed to provide a description, measurements, or location of the MASD in subsequent assessments. The resident's progress notes and weekly skin assessments lacked detailed documentation of the skin condition. Similarly, for Resident #3, the facility did not document a description or follow-up on a previously identified wound. The DON acknowledged not measuring the resident's wound during specific periods and expected the nurses to complete weekly assessments, which were not done.
Neglect of Resident in Special Care Unit
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident being left unchecked for over 11 hours in a locked special care unit. The resident, who had multiple diagnoses including dementia and was dependent on staff for daily activities, was found unresponsive under their bed with dried blood and emesis present. The resident was subsequently sent to the hospital and later passed away. The facility lacked a system to ensure that nursing staff monitored the care provided by aides and that aides performed walking rounds as per facility policy. The facility's policy required CNAs to conduct walking rounds at the beginning and end of each shift and to check on bedridden residents every two hours. However, the CNA responsible for the resident admitted to failing to check on the resident after putting them to bed and even charted on the resident without verifying their condition. The CNA was distracted by personal issues and did not perform the required checks throughout the night. Additionally, the CNA who relieved the primary CNA for a break did not check on the resident or any others during their coverage. Interviews with various staff members, including LPNs and RNs, revealed that the resident was not checked on during the night shift, and the facility's security footage confirmed that no staff entered the resident's room from the time they were put to bed until they were found unresponsive. The facility's failure to ensure regular checks and monitoring of the resident's condition led to the neglect and subsequent death of the resident.
Failure to Maintain Current Facility Assessment
Penalty
Summary
The facility failed to maintain a current and accurate facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both routine operations and emergencies. The facility's census was 71, and the last documented review of the facility assessment was completed in April 2023. The Administrator acknowledged that the annual update for 2024 was not conducted, despite being responsible for reviewing and completing the assessment. It was noted that department heads and the physician should be involved in the assessment process, which should have been reviewed and updated in April 2024. Additionally, the facility did not provide a policy regarding the facility assessment, indicating a lack of procedural guidance for maintaining the assessment's accuracy and currency.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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