Pacific Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pacific, Missouri.
- Location
- 105 South Sixth Street, Pacific, Missouri 63069
- CMS Provider Number
- 265337
- Inspections on file
- 15
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Pacific Care Center during CMS and state inspections, most recent first.
Failure to document wound staging and medication administration: A resident with a coccyx wound had repeated wound assessments that did not include a stage until the wound was later documented as unstageable, despite orders for wound care and staff acknowledgment that nursing and the DON were responsible for staging. Another resident ordered Vancomycin for C. diff had multiple missed or undocumented doses on the MAR, and staff did not notify the nurse or provider when the antibiotic was not administered.
Failure to maintain required RN coverage: Facility records showed repeated weekends with no RN in the building for eight consecutive hours, including multiple gaps across several months. The HR director acknowledged the staffing issue and stated the facility had not realized that split 12-hour shifts would not meet the RN coverage requirement. The DON and administrator both confirmed ongoing RN staffing problems, especially on weekends, with two PRN RNs available.
Medication administration errors exceeded the allowed threshold, with 3 errors in 35 observed opportunities for an 8.57% error rate. One resident's Cephalexin was not given at the ordered time because the CMT said it was unavailable, while another resident's Midodrine and Pantoprazole were administered outside the ordered time window. The DON stated that failing to follow the seven rights of medication administration and giving meds outside the ordered time are medication errors.
Improper medication storage was found in three of five sampled med carts when staff failed to keep drugs and biologicals in their original containers and properly labeled. The D hall cart contained multiple unidentified loose pills and capsules, opened and undated liquid protein, and opened food items with pills; the C hall and A hall carts also contained numerous unidentified loose pills and capsules. The DON, a CMT, and the Administrator each described inconsistent cart maintenance and cleaning expectations, and the Administrator stated the loose pills could lead to med errors.
The facility failed to maintain its IPCP, including missing written and annually reviewed policies and incomplete infection surveillance and antibiotic tracking records. Staff also failed to post EBP signage for a resident with wounds, failed to wear gown and gloves for another resident on EBP, and did not follow TBP for a resident with C-diff when entering the room, providing care, and handling equipment. During medication pass, a CMT and the DON did not perform hand hygiene between residents or after resident contact, despite policies requiring handwashing or antiseptic use before medication administration and between resident contacts.
Failure to Maintain Antibiotic Stewardship Monitoring and Tracking: The facility did not implement its ASP as written, and the IP/DON did not maintain a process to track and trend antibiotic use. Infection/antibiotic control logs were missing for multiple months, and the logs that were completed showed repeated gaps in documentation for signs and symptoms, infection site, onset, culture status, pathogen identification, and infection resolution. The DON stated the logs were not being filled out consistently and that no trending was being done, while the administrator was unaware the monitoring was not occurring.
Staff failed to maintain a comfortable sound level when a broken keypad on a secure exit door caused a loud beeping noise every time the door was used over an extended period. The door, which led to the laundry area and was used frequently by CNAs, laundry, housekeeping, and maintenance staff, emitted a loud alarm-like sound for at least 15 seconds with each use. A resident reported being awakened early in the morning and feeling distressed by the constant beeping, while another resident said the noise sounded like a fire alarm and occurred throughout the day and sometimes at night, bothering everyone. Staff acknowledged the keypad had been broken for weeks, but facility leadership, including the DON and administrator, were unaware of the issue until surveyors arrived, and the maintenance director reported delaying repair pending payment of invoices.
Failure to post accessible State complaint hotline information. The facility did not post the required DHSS hotline information or a list of SA names, addresses, and phone numbers in a form and manner accessible to residents and visitors. Staff posted the Elder Abuse Hotline information in a location that residents, CNAs, and an LPN were not aware of, and a resident said he/she had to find it. The DON and administrator acknowledged the sign may have been too high, too small, and not clearly visible.
Dialysis Care Orders and Clinic Contract Missing: A resident with ESRD who received dialysis had no documented contract between the facility and the dialysis clinic, and the chart lacked physician orders for dialysis and AV graft checks. The resident said staff only sometimes checked the AV graft, while an LPN and the DON confirmed the orders were missing and the facility did not have a copy of the clinic contract.
The facility failed to notify the State LTC Ombudsman of resident transfers to the hospital for four residents. The facility lacked a policy for such notifications, and staff interviews revealed confusion and lack of communication regarding the notification process. The SSD relied on bed hold information from nursing staff, which was not consistently provided, leading to incomplete notifications.
The facility failed to notify residents and their representatives in writing about the bed hold policy during transfers to hospitals or therapeutic leave. This issue affected four residents, with no documentation found in their medical records. Interviews with staff revealed confusion and lack of accountability regarding the completion and monitoring of bed hold forms, contributing to the deficiency.
The facility failed to develop and implement comprehensive care plans for several residents, leading to discrepancies between care plans and physician orders. Issues included inaccurate documentation of hospice services, missing directions for medications and dietary needs, conflicting code status information, and unaddressed use of bed rails and smoking habits. Staff interviews revealed that care plans were not updated as required, contributing to these deficiencies.
The facility failed to provide scheduled showers for eight residents due to an inaccurate master shower schedule. Residents, including those with cognitive impairments and hospice care, were not consistently listed, leading to missed showers. Staff interviews revealed confusion over responsibility for updating the schedule, resulting in inadequate care.
The facility failed to conduct necessary bed rail assessments and obtain informed consent for three residents, despite having a policy requiring these actions. Observations showed consistent use of bed rails without updated assessments or consents. Interviews revealed confusion among staff about responsibilities for bed rail assessments and consent, contributing to the deficiency.
The facility failed to ensure that four nurse aides completed the required training within four months of employment. Personnel files lacked documentation of completed training, and one aide did not perform proper hand hygiene during care. Interviews revealed a lack of clarity and communication regarding responsibility for monitoring training completion, resulting in non-compliance and continued work without completed training.
The facility failed to follow its policy for narcotic reconciliation at shift changes, as narcotic count sheets from April to July 2024 lacked the required two staff signatures. Observations and staff interviews confirmed that narcotic counts were often not performed by two licensed staff members, as required. Facility leadership was unaware of these lapses, which represent a significant deficiency in pharmaceutical services.
Facility staff failed to perform proper hand hygiene during incontinence care for three residents, leading to a deficiency in infection prevention. Staff were observed changing gloves without washing hands, and the facility's handwashing policy lacked guidance on alcohol-based sanitizers. Interviews revealed inconsistencies in the availability of hand sanitizers, complicating adherence to hygiene protocols.
The facility failed to conduct regular inspections of bed rails, leading to potential safety risks for four residents. Despite policy requirements, entrapment assessments were not completed, and observations showed residents with bed rails up without proper documentation. Staff interviews revealed confusion about responsibility for entrapment measurements, posing a risk of harm.
The facility failed to properly contain waste, as the outdoor dumpster was uncovered and lacked lids, with waste scattered around it. This led to two cats rummaging through the waste. The administrator and Dietary Manager were unaware of the lack of a lid and there was no written policy for waste disposal.
A housekeeper in an LTC facility misappropriated funds by stealing a resident's wallet and using the debit card without consent. The resident, who was cognitively intact, reported the missing wallet and unauthorized charges. An investigation confirmed the housekeeper's actions through surveillance footage and interviews, revealing a failure in protecting the resident's belongings.
The facility failed to maintain an operational call light system as staff did not consistently use wireless nurse call pagers, affecting 56 residents. Call lights were often unanswered for extended periods, with staff relying on central computer stations and ticker screens instead of pagers. The DON and administrator acknowledged the issue, emphasizing the need for prompt response to call lights.
The facility failed to update care plans for four residents after falls, despite policy requirements for ongoing assessment and updates. The DON acknowledged responsibility, but care plans lacked new interventions. Communication issues, such as CNAs not having access to event reports and reliance on verbal updates, contributed to the deficiency.
A resident with cognitive impairment and hemiplegia did not receive timely toileting assistance and incontinence care, resulting in the resident remaining wet and unclean. The care plan lacked specific instructions on toileting frequency, and a CNA failed to perform necessary perineal care. Interviews with staff highlighted the importance of regular toileting to prevent skin breakdown and infection.
A CNA failed to secure the safety strap during a mechanical lift transfer for a cognitively impaired resident with hemiplegia, leading to a deficiency in accident prevention. The resident's right arm was not holding onto the lift, and the shin strap was missing. The DON and administrator were unaware of the missing shin strap, despite recent staff training on transfers.
Failure to document wound staging and medication administration
Penalty
Summary
The facility failed to document the stage of a pressure ulcer for one resident with a coccyx wound. The resident’s annual MDS dated 02/06/26 showed cognitive impairment and one or more unhealed pressure ulcers. The care plan dated 01/22/26 identified enhanced barrier precautions related to a nephrostomy tube, feeding tube, and wound, and noted the resident was at risk for pressure ulcer due to nutrition, moisture, and bedfast/mobility status. The physician order sheet for February 2026 directed cleansing the open coccyx area, applying skin prep and Santyl, and covering with calcium alginate every night and as needed. The resident was readmitted from an acute care setting on 01/20/26 with a small pea-sized area above the coccyx. Wound assessments documented a sacral wound measuring 0.7 cm x 0.3 cm x 0.1 cm on 01/20/26 without a stage, no measurements or stage on 01/27/26, and a larger wound measuring 3.5 cm x 2.5 cm x 0.2 cm on 02/03/26 without a stage. The wound was not documented as unstageable until 02/06/26, when the measurement was 3.6 cm x 3.0 cm. During interviews, the LPN said nursing staff were responsible for measuring wounds and the DON was responsible for staging them, and both the LPN and DON acknowledged the wound was not staged from 01/20/26 to 02/06/26. The facility also failed to document administration of Vancomycin for another resident. The resident’s MDS showed cognitive impairment and isolation/quarantine for active infectious disease, and the care plan dated 01/19/26 identified antibiotic treatment for C. diff. The physician order sheet for January 2026 ordered Vancomycin 125 mg four times daily, but the MAR did not document administration on 01/09/26 through 01/11/26, 01/15/26, 01/19/26, 01/20/26, and 01/22/26. Nursing notes did not show staff notified the nurse or doctor that the medication was not administered. During interviews, the CMT said he/she marked the medication as not available even when it was in the cart, the LPN said staff would assume the medication was not in the cart if it was documented as not administered, and the DON and Administrator said they were not aware the antibiotic was unavailable or not given.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. Review of the facility’s Payroll Based Journal report for FY 2025 Q4 showed no RN hours on multiple Saturdays and Sundays in July, August, and September 2025. Review of the RN staff schedules for July, August, September, October, December 2025, and January through February 2026 also showed repeated days when no RN was in the building for eight consecutive hours, including weekends across several months. During interviews, the Human Resource director stated he/she was responsible for schedules and PBJ reporting and acknowledged not realizing that 12-hour nurse shifts split across two days would not satisfy the eight-hour RN requirement. The DON stated HR and the administrator handled staffing, that the facility had issues with RN coverage, that weekends lacked coverage, and that two as-needed RNs were available. The administrator also stated she was aware of the non-coverage of RN hours and that the facility had staffing difficulties.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Facility staff failed to ensure the medication error rate remained below 5%, as surveyors identified 3 medication errors out of 35 observed opportunities, resulting in an 8.57% error rate and affecting two residents. Facility policies reviewed did not contain a definition of a medication error, although the Medication Errors and Drug Reactions policy directed staff to report all medication errors immediately to the physician, DON, and administrator. The DON stated staff are expected to follow the seven rights of medication administration and that failing to do so could result in a medication error. For one resident, an order for Cephalexin 500 mg four times daily was observed as not administered at the ordered time because the CMT documented it as unavailable and said it was not in the emergency kit, while the DON later verified one tablet was in the emergency supply kit and stated the medication should have been pulled for use. For another resident, Midodrine 5 mg daily before breakfast and Pantoprazole 40 mg three times daily were observed being administered outside the ordered time window, and the CMT stated these medications were frequently given late because the night shift did not have enough staff to complete them on time. The DON acknowledged there were medication timing issues with the night shift and stated that giving medication outside the ordered time is a medication error.
Improper Medication Cart Storage and Labeling
Penalty
Summary
Staff failed to ensure medications were stored in a safe and effective manner when three of five sampled medication carts contained improperly stored and unlabeled items. Review of the facility policy showed medications must be stored in the container in which they were received and that no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. During observation, the D medication cart on the B hall contained 19 and a half unidentified loose pills, nine unidentified loose capsules, 30 ounces of opened and undated active liquid protein, one medication cup with three unidentified pills, and one small opened and undated pudding cup. Additional observations showed the C medication cart on the B hall contained 15 and a half unidentified loose pills and one unidentified capsule, and the A medication cart on the B hall contained 22 and a half unidentified loose pills and two unidentified capsules. The DON stated the CMTs passing medications on that shift were responsible for maintaining their cart and said carts should be monitored and cleaned daily as needed, but was not aware there were so many loose pills in the carts. A CMT stated there was no schedule to clean the medication carts and that the carts had not been cleaned. The Administrator stated it was the responsibility of the CMTs to maintain medication carts and that they should be cleaned at least weekly and follow the facility's medication storage policy.
Infection Control Program, Precautions, and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Review of the facility’s IPCP materials showed there was no written IPCP policy, the IPCP Procedure Manual was undated and had not been reviewed annually, and the Antibiotic Stewardship binder did not contain infection surveillance or antibiotic tracking documentation for January through May 2025 and January through February 11, 2026. During interviews, the DON stated he/she was the facility Infection Preventionist and was responsible for maintaining the IPCP, and the Administrator stated the IPCP policies and procedures should be reviewed annually. For one resident with wounds and on Enhanced Barrier Precautions, staff did not post the required EBP sign outside the room on multiple observations. The resident’s care plan indicated signage would be on the door to notify staff of EBP, and the physician order sheet showed treatment for a left heel open area with dressing changes. Observations on several dates showed the door did not have an EBP sign or PPE outside the room. The DON stated staff should wear gowns and gloves for EBP and said a sign should have been placed on the resident’s door because the resident had a wound. For another resident with an open coccyx wound and on EBP related to a nephrostomy tube, feeding tube, and wound, staff did not wear a gown or gloves when removing the wound dressing. The resident’s care plan stated staff would wear appropriate PPE while caring for the resident according to EBP, and the physician order sheet showed ongoing wound treatment. The LPN acknowledged he/she should have put on a gown and gloves before touching the wound dressing and said he/she forgot to do so. The DON and Administrator both stated staff were expected to follow the EBP guidance before touching the wound dressing. The facility also failed to follow transmission-based precautions for a resident with C-diff. The resident’s records showed isolation/quarantine for active infectious disease and nursing notes documented C-diff treatment with isolation precautions and PPE use. During observation, a CNA entered the resident’s room, touched the bedrail and call light, left the room, and then entered other residents’ rooms without applying PPE or performing hand hygiene after contact with the resident. During another observation, the DON entered the resident’s room during medication pass, administered medications and took blood pressure, then placed the blood pressure cuff on the medication cart and moved to another resident’s room without PPE, hand hygiene, or disinfecting the equipment. The DON later stated he/she did not apply the gown and gloves, did not hand wash between med passes, and did not disinfect the equipment after use. Hand hygiene was also not performed appropriately during a medication pass for five residents. The facility’s handwashing policy did not include direction on when to wash hands, although other policies stated staff should wash hands before administering medication and clean hands between resident contacts. During observation, a CMT administered medications to multiple residents and moved between residents without washing or sanitizing hands, including after handling a soiled gown and after taking a resident’s blood pressure. The CMT stated he/she was supposed to wash or sanitize hands between residents during medication pass but forgot. The DON stated staff were expected to wash or sanitize between residents during medication pass.
Failure to Maintain Antibiotic Stewardship Monitoring and Tracking
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility policy directed the Infection Preventionist (IP) or designee to audit antibiotic prescribing documentation, including dose, route, start date, end date, days of therapy, and indication, and to track C. difficile and antibiotic-resistant infections. However, staff did not have a process in place to track and trend antibiotic usage, and the facility did not have infection/antibiotic control logs for January through May 2025 or for January through February 2026. Review of the facility's infection/antibiotic control logs showed incomplete documentation for multiple antibiotics. In September 2025, 24 antibiotics were used, with missing documentation for signs and symptoms, site of infection, onset of symptoms, culture status, and pathogen identification. In October 2025, 24 antibiotics were used, with similar missing documentation. In November 2025, 12 antibiotics were used, with missing documentation for signs and symptoms, site of infection, culture status, and pathogen identification. In December 2025, seven antibiotics were used, and all seven lacked documentation of signs and symptoms, with additional missing information for site of infection, culture status, and whether the infection was resolved. During interviews, the DON stated he/she was the IP, was responsible for the program, and was unsure why it had not been completed before starting; he/she also stated the logs had not been filled out for the last two months and that no trending was being done. The administrator stated the DON was responsible for maintaining the program and was not aware that the logs and trending were not being done.
Failure to Maintain Comfortable Sound Levels Due to Broken Exit Door Keypad
Penalty
Summary
Facility staff failed to maintain a comfortable and homelike environment by not ensuring a functional keypad on the secure metal door leading to an outside exit on C hall, resulting in a loud, continuous beeping noise each time staff entered or exited. The facility lacked an environmental policy, and the keypad had been broken for at least a couple of weeks, according to staff. The beeping occurred whenever staff held down the metal bar for 15 seconds to open the door and continued until a code was entered on the other side. Multiple observations over several days showed frequent, loud beeping from this door as various staff, including maintenance, CNAs, laundry, and housekeeping personnel, repeatedly used the door throughout the day. Each observed use required holding the bar down for 15 seconds, triggering the loud alarm-like sound. This occurred many times in a short period on multiple days, demonstrating an ongoing and unresolved environmental issue affecting the sound level in the hallway. Residents reported that the noise disturbed their rest and comfort. One resident stated the beeping came from the broken back door to the laundry room, reported that staff began arriving early in the morning, and said the noise often woke them up and made them feel "crazy." Another resident said the loud beeping sounded like a fire alarm, believed the door was broken, and reported being awakened in the mornings and hearing the sound periodically all day and sometimes at night, stating it bothered everyone. Staff interviews confirmed awareness of the broken keypad and frequent use of the door, while leadership interviews showed that the DON and administrator were not aware of the problem until the surveyors arrived, and that the maintenance director was waiting on invoices to be paid before ordering the needed part.
Failure to Post Accessible State Complaint Hotline Information
Penalty
Summary
The facility failed to post the required DHSS hotline information for reporting allegations of abuse and neglect, or a list of names, addresses, and phone numbers of the State Survey Agency, in a form and manner accessible to residents and visitors. The census was 53.1. Review of the facility’s policies showed there was no policy addressing the required postings. On observation, staff had posted the Elder Abuse Hotline number and contact information, but it was not accessible to all residents and resident representatives. During interviews, Resident #44 said he/she was not aware of the number being posted in the building but found it, and Resident #1 said he/she was not aware of the hotline number or its posted location. CNA E, CNA F, and LPN A each stated they were not aware of the hotline number or where it was posted. The DON said the hotline number was in the hall by the main entry and acknowledged it might be too high and the font size might be too small for residents to use discreetly. The administrator said the sign was in the hall of the front office, but was not sure it was visible from its location and thought it should be lowered and the font made larger.
Dialysis Care Orders and Clinic Contract Missing
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who received dialysis at an outside clinic. The resident had intact cognition, a diagnosis of ESRD, and received dialysis on Monday, Wednesday, and Friday. The resident's record did not contain a contract between the facility and the dialysis clinic, and the physician order sheet for February 2026 did not include an order for dialysis or an order to check the resident's AV graft. The MAR also did not include direction for staff to check the AV graft. During interview, the resident stated the AV graft was in the left arm and that the dialysis clinic covered the site with band aids after treatment, while facility staff only sometimes checked the graft. An LPN stated he/she did not know whether the facility had a contract with the dialysis clinic and said the resident should have physician orders for dialysis and for AV graft checks, but those orders were not present and may have been overlooked. The DON stated the facility believed it had a contract but did not have a copy, and also said there was no order in place directing staff to check the AV graft. The administrator stated the facility had been trying for weeks to obtain a contract from the dialysis clinic but had not received one.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility staff failed to notify the State Long-Term Care Ombudsman in writing of resident transfers to the hospital, including the reason for transfer, for four residents out of 14 sampled. The facility's policies did not include a procedure for notifying the ombudsman about transfers and discharges. The medical records of the residents involved did not contain documentation that the ombudsman was notified of their transfers to acute care or the emergency room. This lack of notification was identified for residents who were transferred on various dates and subsequently readmitted to the facility. Interviews with facility staff revealed a breakdown in the notification process. The Social Service Director (SSD) indicated that notifications to the ombudsman were dependent on receiving bed hold information from nursing staff, which was not consistently completed. The Administrator acknowledged the issue, stating that ombudsman notifications were not being completed as required. Other staff members, including an LPN, the ADON, and a Nurse Consultant, were either unaware of the notification responsibilities or the fact that notifications were not being completed. This indicates a lack of clarity and communication among staff regarding the notification process for resident transfers.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their representatives in writing about the bed hold policy at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for four residents out of a sample of 14, with the facility's census being 54. The facility's Bed Hold Policy Guidelines require notification upon admission, at the time of transfer, and during non-covered therapeutic leave. However, reviews of the medical records for the affected residents showed no documentation of such notifications being provided prior to their transfers. Interviews with facility staff, including the Social Service Director, the administrator, LPNs, the ADON, and the Nurse Consultant, revealed a lack of clarity and accountability regarding the completion and monitoring of bed hold forms. The charge nurses were identified as responsible for completing these forms, but there was a breakdown in the process, as evidenced by the absence of completed forms. The administrator acknowledged awareness of the issue, while the ADON and Nurse Consultant were unaware that the bed holds were not being completed. This lack of communication and oversight contributed to the deficiency in notifying residents and their representatives about the bed hold policy.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for seven residents out of a sample of 14, despite having a policy in place to use the CMS Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual as a guide. For Resident #16, the care plan inaccurately documented hospice services even after the resident was discharged from hospice, and there was no corresponding physician order for hospice care. Resident #21's care plan lacked directions for anticoagulant medication and nectar thickened liquids, despite the resident being on Xarelto and requiring a mechanical soft diet. Resident #25's care plan contained conflicting code status information, listing both full code and Do Not Resuscitate (DNR) status, and failed to include directions for toileting, hygiene, dressing, or the use of a right arm tray on the wheelchair, despite the resident's observed needs. Resident #32's care plan did not include a plan for hospice care, even though the resident had a signed contract and consent for hospice services. Resident #33's care plan did not address the use of bed rails, which were observed in use, and there were no corresponding physician orders for bed rail use. Resident #49's care plan was missing directions for code status and bed rail use, despite observations of the resident using bed rails and having a full code status order. Resident #50's care plan did not address the resident's smoking habits, even though the resident was documented as a smoker and confirmed this during an interview. Interviews with facility staff, including CNAs, LPNs, the ADON, and the Administrator, revealed that care plans were not updated as required, and there was a lack of alignment between care plans and physician orders, leading to deficiencies in resident care planning.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility staff failed to provide activities of daily living (ADLs), specifically showers, for eight residents out of fourteen sampled. These residents were not consistently listed on the master shower schedule, leading to missed showers. The facility's policy required residents to be on the shower schedule twice a week, but this was not adhered to, resulting in some residents not receiving showers as needed. Resident #9, who was severely cognitively impaired and dependent on staff for hygiene and bathing, was not on the master shower list. Similarly, Resident #21, who required maximum assistance for transfers, toileting, and dressing, was listed to receive showers twice a week, but there was no documentation to confirm these showers were provided. Resident #23, who was cognitively intact but required assistance for bathing, reported not receiving showers twice a week as scheduled, leading to discomfort. The facility's failure to maintain an updated and accurate master shower schedule contributed to the deficiency. Interviews with staff, including the Certified Medication Technician (CMT), Certified Nurse Assistant (CNA), Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON), and the administrator, revealed a lack of clarity and responsibility in updating the shower schedule. This oversight resulted in residents, including those receiving hospice care, not being offered showers as required, highlighting a systemic issue in the facility's management of resident care.
Failure to Conduct Bed Rail Assessments and Obtain Consent
Penalty
Summary
The facility failed to complete necessary bed rail assessments and obtain informed consent for the use of bed rails for three residents out of a sample of 14, despite having a policy in place that requires these actions. The policy mandates staff to conduct bed rail observations, obtain consent, educate residents or their representatives on the risks and benefits, and develop a care plan for bed rail use. However, for Residents #21, #33, and #49, these steps were not followed, as evidenced by the lack of documented assessments and consents in their medical records. Resident #21 was assessed as requiring maximum assistance for various activities and had physician orders for bed rails, yet the medical record showed only one bed rail assessment and consent, with no further documentation. Observations confirmed the consistent use of bed rails without updated assessments or consents. Similarly, Resident #33, who was cognitively intact and required supervision for some activities, had no documented bed rail assessment or consent, despite observations showing the use of bed rails. Resident #49, with severe cognitive impairment, also lacked documentation for bed rail assessments and consents, although bed rails were observed in use. Interviews with facility staff revealed confusion and inconsistency regarding responsibilities for bed rail assessments and consent. LPN C, the maintenance person, the Nurse Consultant, and the Administrator provided conflicting information about who was responsible for these tasks and how often they should be completed. The maintenance person admitted to not performing entrapment measurements, and there was uncertainty about who should conduct these measurements. This lack of clarity and adherence to policy contributed to the deficiency in ensuring resident safety regarding bed rail use.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that four nurse aides completed the required nurse aide training program within four months of their employment. The facility's policy did not provide guidelines for the completion of the nurse aide training program, and the Facility Assessment Tool indicated that all nurse aides must be certified within 120 days. Personnel files for the nurse aides in question lacked documentation of completed training, and observations revealed that one of the nurse aides did not perform proper hand hygiene during care procedures. Interviews with various staff members, including the Business Office Manager, Administrator, Director of Nursing, ALF Coordinator, Assistant Director of Nursing, and Nurse Consultant, revealed a lack of clarity and communication regarding the responsibility for monitoring the completion of the CNA training. The ALF Coordinator was identified as responsible for tracking CNA class completion, but there was a breakdown in communication and follow-up, resulting in the nurse aides being out of compliance and continuing to work without completing their training. The facility staff were aware of the issue but did not take effective action to address it, leading to the deficiency.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility staff failed to adhere to their policy regarding the reconciliation of narcotics at the change of shift. The policy required that narcotics be counted and verified by two licensed staff members at each shift change, with both individuals signing the narcotic count log to confirm the accuracy of the count. However, a review of the narcotic count sheets from April to July 2024 revealed numerous instances where the sheets lacked the required two signatures, indicating that the counts were not consistently performed by two staff members as mandated. Observations and interviews with staff members further confirmed the deficiency. On one occasion, an LPN was observed beginning their shift without completing a narcotic count with the outgoing nurse. Interviews with various staff, including LPNs, CMTs, the Assistant Director of Nursing, and the Nurse Consultant, revealed a pattern of non-compliance with the narcotic counting procedure. Staff members admitted to either not performing the counts or doing so alone, contrary to the facility's policy. The facility's leadership, including the Administrator and the Director of Nursing, were unaware of the lapses in narcotic counting procedures. They expressed expectations that the counts be completed by two licensed staff members at each shift change and that both sign the narcotic log. The failure to consistently follow the established procedure for narcotic reconciliation at shift changes represents a significant deficiency in the facility's pharmaceutical services.
Deficiency in Hand Hygiene Practices
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols, leading to a deficiency in infection prevention and control. Observations revealed that staff members did not perform hand hygiene after glove removal and before donning new gloves during incontinence care for three residents. For Resident #14, staff members were observed changing gloves without washing hands after providing bowel incontinence care. Similarly, for Resident #24, a CNA applied barrier cream with soiled gloves and changed gloves without hand hygiene. For Resident #35, a CNA changed gloves multiple times during catheter and incontinence care without performing hand hygiene. The facility's handwashing policy did not address the use of alcohol-based hand sanitizers or provide specific guidance on when to wash hands. Interviews with staff indicated a lack of available hand sanitizers in resident rooms, complicating adherence to proper hand hygiene practices. The Director of Nursing acknowledged the expectation for staff to perform hand hygiene during care transitions and noted that pocket-sized hand sanitizers were available, although the Administrator contradicted this by stating they were not available to staff.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed rails as part of their maintenance program, leading to potential safety risks for four residents. The facility's policy required regular inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment, but this was not adhered to. The FDA guidelines highlight the risks associated with bed rails, including entrapment, strangulation, and other injuries, particularly for vulnerable populations such as the elderly. Resident #21 was assessed as requiring maximum assistance for various activities and had an order for bed rails for positioning. However, there was no entrapment assessment or measurements in the resident's medical record, and observations showed the resident consistently had both half bed rails up. Similarly, Resident #25 had moderate cognitive impairment and required assistance for mobility and other activities. The bed rail assessment for this resident showed measurements that did not pass the entrapment criteria, yet staff documented them as passed. Residents #33 and #49 also had discrepancies in their care plans and medical records regarding bed rail use and entrapment assessments. Observations showed both residents with half bed rails up, but their records lacked necessary entrapment measurements. Interviews with staff revealed confusion and lack of clarity about who was responsible for conducting entrapment measurements, with different staff members providing conflicting information. This lack of coordination and adherence to safety protocols posed a risk of harm to the residents.
Improper Waste Containment
Penalty
Summary
The facility staff failed to properly contain waste and refuse, leading to the potential harboring and feeding of rodents and pests. Observations on two consecutive days revealed that the outdoor dumpster, which contained waste, was uncovered and lacked lids or doors. Additionally, paper and food waste were scattered on the ground around the dumpster, and a plastic bag of waste was found on the ground near the dumpster. On the second day, two cats were observed rummaging through the plastic bag of waste. Interviews with the facility administrator and the Dietary Manager revealed that there was no written policy for waste disposal or maintenance of waste disposal areas, and both were unaware that the dumpster did not have a lid.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
Facility staff failed to prevent the misappropriation of funds for a resident when a housekeeper stole the resident's wallet and used the debit card without consent. The facility's policy mandates protection of residents from abuse, neglect, exploitation, and misappropriation of property. Despite this, the housekeeper accessed the resident's room, took the wallet, and used the debit card for unauthorized transactions totaling $308.96. The resident, who was cognitively intact, noticed the wallet missing and reported unfamiliar charges to the bank. The facility conducted an investigation and involved the Department of Health and Senior Services and the local police. The police confirmed the housekeeper's unauthorized use of the debit card through surveillance footage and interviews. The housekeeper admitted to taking the wallet and using the card without permission. The incident highlights a failure in safeguarding the resident's belongings, as the housekeeper had access to the resident's room and exploited this access for personal gain.
Failure to Ensure Operational Call Light System
Penalty
Summary
The facility staff failed to ensure the wireless call light system was fully operational at all times, as direct care staff did not consistently carry and utilize the wireless nurse call pagers. This deficiency had the potential to affect all 56 residents in the facility. The facility's policy on call light answering did not provide clear instructions on the use of pagers, and an approved exemption required staff to carry and use the pagers at all times to ensure resident care was not adversely affected. The call light report from a specific period showed numerous instances where call lights were not answered promptly, with delays ranging from 31 to 166 minutes. Observations revealed that the facility relied on a central call light computer station and scrolling ticker screens at the end of hallways to alert staff, rather than individual pagers. Interviews with staff members, including CNAs and a CMT, indicated that pagers were often not worn due to being lost or taken home, and staff relied on the ticker screens and computer stations to monitor call lights. The Director of Nursing and the administrator acknowledged the issue, noting that staff should wear pagers to be alerted immediately when a call light is activated. They stated that call lights should be answered within 15 minutes, with a maximum acceptable delay of 30 minutes. However, the report documented that call lights were frequently left unanswered for much longer periods, which could potentially result in harm to residents.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility staff failed to revise comprehensive person-centered care plans for four residents who experienced falls. The facility's policy requires ongoing assessment and updating of care plans when significant changes occur in a resident's condition. However, the care plans for these residents did not include new interventions or reviews following their falls, despite the Director of Nursing (DON) acknowledging responsibility for ensuring updates after such incidents. Resident #2, who is cognitively impaired and has a history of falls, was found on the bathroom floor, but the care plan was not updated with new interventions. Similarly, Resident #13, who is cognitively intact with a seizure disorder and traumatic brain dysfunction, experienced two falls, yet the care plan lacked new interventions. Resident #14, also cognitively intact, fell while attempting to get into bed without assistance, but the care plan did not reflect any new interventions. Resident #18, with schizophrenia, fell from bed, but the care plan was not updated despite an increase in antipsychotic medication. The facility's process for communicating care plan updates to staff was inadequate. CNAs do not have access to event reports, and the DON relies on nurses to verbally communicate changes. The MDS nurse is responsible for ensuring care plan updates, but the lack of access to event investigations for floor staff and reliance on verbal communication led to deficiencies in care plan updates after falls.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
Facility staff failed to provide timely toileting assistance and incontinence care for a resident, leading to the resident remaining unclean and wet. The resident, who was cognitively impaired and had functional impairment on one side due to hemiplegia, required substantial assistance for toileting and was frequently incontinent of bladder and occasionally incontinent of bowel. The care plan did not specify how often to offer toileting or provide incontinence care. During an observation, a CNA transferred the resident to the toilet and found the resident's clothing and wheelchair pad saturated with urine. The CNA did not perform perineal care, leaving the resident with a smell of urine. Interviews with facility staff, including the CNA, DON, and administrator, revealed that residents should be toileted every two to three hours to prevent skin breakdown and infection. The CNA admitted to being in a hurry and not performing the necessary perineal care, while the DON and administrator emphasized the importance of regular toileting and perineal care. The facility's Perineal Care policy lacked specific instructions on the frequency of care, contributing to the deficiency.
Failure to Secure Safety Straps During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide safe transfers with a mechanical lift for a resident, leading to a deficiency in accident prevention. The facility's Hydraulic Lift policy, which was undated, required adherence to the manufacturer's instructions for safe use. The hydraulic lift manual from September 2023 specified that residents should have some weight-bearing ability, upper body strength, and the ability to follow simple commands. It also required the safety strap to be securely fastened around the resident's torso, with the resident's arms positioned outside the harness and hands on the paddle handles. Additionally, if necessary, shin straps should be used to keep the resident's feet on the footplate. During an observation, a CNA assisted a cognitively impaired resident with hemiplegia in a transfer using the lift but failed to secure the safety strap around the resident's torso. The resident's right arm was not holding onto the lift, and the shin strap was missing. The CNA acknowledged the missing shin strap and the need to secure the chest strap. Interviews with the DON and the administrator revealed that staff had received transfer training, and both were unaware of the missing shin strap. The administrator expected staff to use the lift as intended by the manufacturer to prevent falls or injuries.
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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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