Parkview Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 128 North Hardesty, Kansas City, Missouri 64123
- CMS Provider Number
- 265463
- Inspections on file
- 37
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Parkview Healthcare during CMS and state inspections, most recent first.
Two residents with significant medical comorbidities, including CHF, ESRD, CVA with hemiplegia, and documented ADL/self-care deficits, were involved in an unwitnessed physical altercation after one resident allegedly entered the other’s room and took cigarettes. One resident reported being followed back to their room and struck multiple times, including being kicked near a dialysis port and scratched on the face, while the other resident later admitted to punching the first resident three times and then falling when losing balance. The first resident sustained a chest wall contusion and facial abrasion confirmed by hospital evaluation and reported severe pain, and the second resident reported right hip pain after the fall. Staff and leadership acknowledged the event as abuse, and records showed the aggressive potential of one resident had been identified in the care plan, yet the facility failed to prevent this resident-to-resident physical abuse.
Surveyors found that the facility’s call light system did not provide audible or visual alerts beyond a computer screen at the nurse’s station, and staff often did not monitor it, resulting in prolonged response times far exceeding the facility’s 5–10 minute expectation. Several residents with hemiplegia, COPD, acute respiratory failure, multiple sclerosis, severe mobility limitations, incontinence, and continuous O2 reported waiting from tens of minutes to many hours for assistance, sometimes lying in urine or bowel for extended periods, being unable to reach their call lights, or running out of oxygen without timely help. Observations confirmed call lights active for over 30 minutes with no hallway indicators while staff sat at the nurse’s station on cell phones, and device reports documented numerous call responses taking from about 20 minutes to several hours, demonstrating a systemic failure to ensure accessible, functional call lights and prompt staff response.
A resident with COPD, acute respiratory failure with hypoxia, and pneumonia had care plan interventions and physician orders requiring monitoring of respiratory status, oxygen saturation, and PRN oxygen at 2 L/min via nasal cannula for O2 saturation below 90% and/or wheezing and shortness of air. For an entire month, the MAR showed no documentation of oxygen administration or O2 saturation checks, and an oxygen saturation summary showed only two assessments over several months. The resident, who was cognitively intact, reported repeated pneumonia episodes, nighttime shortness of air, and that staff did not check O2 saturation, and there was no oxygen equipment in the room despite an active PRN order. Interviews with an RN, CMTs, CNAs, an LPN, and the Administrator/DON revealed inconsistent understanding of responsibilities, lack of awareness of the resident’s respiratory and oxygen orders, gaps in documentation, and a practice of obtaining vitals only monthly, resulting in failure to follow the ordered respiratory monitoring and PRN oxygen therapy.
The facility failed to assess, care plan, and implement behavioral health and substance use interventions for three residents with known substance use disorders, despite PASRR findings and facility policies requiring person‑centered behavioral health services and care plans addressing illicit drug and alcohol use. One resident with a history of polysubstance abuse had no substance use risk assessment, no documented substance abuse programming, and no care plan addressing illicit drug use or PASRR recommendations; this resident was repeatedly found with drug paraphernalia and placed on various "restrictions" that were not clearly defined, documented, or implemented, and visitor and LOA sign‑out logs were incomplete or absent. Two other residents with documented alcohol and polysubstance dependence and a need for 24‑hour supervision had no substance use risk assessments, no care plan goals or interventions for their substance use disorders, and no documentation of NA/AA resources or education. Subsequently, the resident on restriction obtained fentanyl, used it in a room with the other two residents, and both of those residents became unresponsive after smoking the substance, required multiple doses of Narcan administered by LPNs, and were transported to the hospital for overdose‑related treatment.
A resident with psychiatric and neurologic diagnoses overdosed on fentanyl, received two doses of Narcan, became alert, and was transported by ambulance to the hospital. Although facility records indicated the guardian was notified shortly after the event, the guardian later reported learning of the overdose from the resident and stated that no one had called the provided emergency cell or other on‑call contacts. An LPN reported leaving a voicemail on an office line, and the DON acknowledged that the nurse had not used the correct emergency number and that leaving a voicemail was treated as sufficient notification. As a result, the guardian was not promptly and effectively informed of the resident’s significant change in condition and hospital transfer, contrary to the facility’s own notification policy.
The facility did not follow pest control recommendations or address structural issues such as unsealed holes, gaps under doors, and improperly placed dumpsters, resulting in ongoing rodent activity in multiple resident rooms and common areas. Residents and staff reported frequent mouse sightings and droppings, and observations confirmed numerous entry points for pests throughout the building.
A resident admitted with frostbite and a chronic wound did not receive prescribed opioid pain medication due to incorrect transcription of physician orders and lack of clarification when the medication was not received from the pharmacy. Nursing staff provided alternative non-opioid pain medications, but the opioid was not administered, and there was insufficient follow-up and documentation regarding the missing medication.
A resident with a history of mental illness was physically assaulted by another cognitively intact resident, who struck the victim multiple times on the head with a cane, causing a laceration requiring stitches and additional injuries. The attack was unprovoked, captured on video, and confirmed by witness interviews. Facility staff and policies did not identify or prevent the risk of this altercation, and the victim expressed fear and pain following the incident.
The facility reported excessively low weekend staffing levels, potentially affecting 112 residents' care. Despite continuous hiring efforts, the facility struggled to maintain adequate staffing, particularly on weekends, as confirmed by the Staffing Coordinator and DON. The staffing data for 2024 indicated a one-star rating, highlighting the facility's challenges in meeting its staffing policy requirements.
The facility failed to provide RN coverage for at least eight hours per day during three quarters of 2024, as required by regulations. This deficiency was identified through staffing reports submitted to CMS, indicating no RN hours for the first, second, and fourth quarters. Interviews revealed challenges in hiring RNs for night shifts, despite recruitment efforts. The lack of RN coverage potentially impacted the care of 112 residents.
The facility failed to employ a qualified CDM or professional to manage the dietary department without a full-time Registered Dietitian. The DM lacked formal training, leading to issues with food palatability, unmet resident preferences, and unsanitary food conditions. Complaints were noted in Resident Council Meeting Minutes, and the DON confirmed the DM's lack of qualifications.
The facility failed to maintain sanitary conditions in food storage, preparation, and distribution, affecting all residents. The handwashing sink did not meet FDA temperature standards, and kitchen equipment was found soiled. Staff mishandled clean and soiled items, and food temperatures were not properly recorded, leading to unsafe serving temperatures. Desserts were served uncovered, exposing them to contamination during transport.
The facility failed to properly dispose of garbage and refuse, as the dumpster lid behind the kitchen was repeatedly observed open. The Dietary Manager confirmed that all departments were responsible for closing the lid after discarding trash. This oversight had the potential to increase the risk of pests affecting all 112 residents.
The facility did not have a Quality Assurance and Performance Improvement (QAPI) plan in place, as required to guide care and services for residents. The new Administrator was unaware of the QAPI plan, and the Director of Nursing (DON) could not provide previous meeting records. This deficiency had the potential to affect the care and services for 112 residents.
The facility failed to address grievances voiced by the Resident Council, including issues with food temperature, staff interactions, pest control, and call light response times. Despite repeated documentation of these concerns in council minutes, no actions were taken to resolve them. Interviews with residents and the DON confirmed the lack of follow-up or resolution, indicating a failure to adhere to facility policies on grievance handling.
The facility failed to protect residents from abuse, as evidenced by incidents involving four residents. A cognitively intact resident reported being hit by a roommate with a history of aggression, and another resident felt unsafe due to repeated aggressive encounters with a fellow resident. The facility's policy on abuse prevention was not effectively implemented, leading to these altercations.
The facility failed to report resident-to-resident altercations to the SSA within the required timeframe. Incidents involving physical altercations between residents were not reported, despite facility policies mandating immediate reporting. The Administrator did not report these incidents, resulting in a deficiency in compliance with federal requirements.
The facility failed to investigate allegations of resident-to-resident abuse involving four residents. One incident involved a resident with intact cognition allegedly hitting another with moderately impaired cognition, with no evidence of investigation. Another incident involved a resident with moderately impaired cognition allegedly grabbing and striking another resident, with missing investigation components. The facility did not adhere to its abuse prevention and investigation policy, as evidenced by incomplete investigations and lack of documentation.
The facility failed to ensure accurate documentation of narcotic administration for three residents, leading to discrepancies between the electronic MAR and the Controlled Drug Administration Record. Despite being administered, several doses of oxycodone and buprenorphine were not recorded on the MAR, increasing the risk of medication errors. Interviews with staff revealed that while narcotics were documented on paper logs, they were not consistently recorded in the electronic MAR, contrary to facility policy.
The facility failed to properly label and store medications, including insulin pens, on two medication carts. Observations revealed unlabeled and undated insulin pens, expired medications, and improper storage of personal items and food with medications. Both an LPN and an RN acknowledged the issues, and the DON confirmed the expectations for labeling and storage.
The facility failed to provide palatable and appetizing meals, with food served at inadequate temperatures, affecting all residents reviewed for food concerns. Observations showed food temperatures were lower than recorded, impacting taste. Residents consistently reported dissatisfaction with cold and unappetizing meals, and the facility did not address ongoing grievances from the Resident Council, risking weight loss among residents.
The facility did not inform 29 residents and/or their representatives that signing a binding arbitration agreement was not a condition for admission or continued care. The arbitration agreement lacked a statement clarifying this, placing residents at risk of involuntary agreement. The Admissions Coordinator confirmed the omission, and the facility's policy required such a statement, which was not followed.
The facility failed to inform 29 residents about their right to select a neutral arbitrator agreed upon by both parties in the binding arbitration agreement. The facility's Arbitration Agreement Rider did not include this provision, as confirmed by the Admissions Coordinator. This oversight was identified through interviews and policy reviews, placing residents at risk of misunderstanding the arbitration process.
The facility failed to assess, educate, and offer the pneumococcal vaccine to five residents with various medical conditions, including paraplegia and heart disease. The Infection Preventionist, new to the role, confirmed the absence of documentation for offering or administering the vaccine, contrary to the facility's policy requiring such actions within a specified timeframe.
The facility failed to maintain a safe and comfortable environment, with issues such as disrepair in walls, broken heating vents, and missing mirrors affecting several residents. A newly hired Regional Maintenance Consultant noted these problems, and residents reported discomfort due to the conditions. The facility's policy on maintaining a homelike environment was not followed, as maintenance issues were not promptly addressed.
The facility failed to implement effective pest control measures, leading to a mouse infestation affecting several residents and common areas. Despite repeated recommendations from pest control reports to fix entry points and remove trash, the facility did not act, resulting in ongoing rodent activity. Residents reported seeing mice and finding droppings in their rooms, causing distress. The Regional Maintenance Consultant noted the facility's inaction and the Maintenance Director's need for training.
The facility failed to respect residents' rights to privacy and autonomy, affecting three residents. One resident experienced a breach of privacy when staff entered without knocking, while another was disturbed by loud, inappropriate language from staff. A third resident's refusal of a meal tray was ignored, despite their right to refuse. These incidents indicate a lack of communication and awareness among staff regarding residents' rights.
The facility failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055, to three residents whose Medicare Part A services were no longer covered. Two residents did not receive the form, and one received an expired version. The Social Service Director was unaware of the requirement and did not notice the expiration, leading to a lack of proper notification for residents to make informed decisions about their care.
A resident with multiple medical conditions experienced a significant weight loss of 7.88% over one month, which was not accurately reflected in the MDS assessment. The Dietary Manager failed to use the most recent weight, leading to an incorrect recording of the resident's weight. Interviews revealed a lack of awareness of the weight loss, despite the facility's policy on accurate assessments.
A facility failed to complete a PASARR Level I screening for a resident admitted with major depressive disorder, schizoaffective disorder, PTSD, and substance abuse. The absence of this screening, confirmed by the Social Service Director, violated the facility's policy requiring pre-admission screening for serious mental disorders. This oversight meant the resident could be residing in the facility without the necessary state mental health authority's determination of appropriateness for admission.
The facility failed to implement safety interventions for two residents with substance use disorders. One resident tested positive for fentanyl and was implicated in providing drugs to others, while another was hospitalized for an opioid overdose. Both residents' care plans lacked necessary interventions for monitoring and prevention of substance use, despite staff expectations and facility policy.
The facility failed to safely store portable compressed oxygen cylinders and maintain respiratory equipment in a sanitary manner. Observations revealed unsecured oxygen cylinders in the hallway and storage room, posing a risk of explosion. Additionally, a resident's oxygen tubing was found on the floor with outdated markings, and the concentrator filter was dusty. Staff interviews confirmed the lack of adherence to safety policies, highlighting potential dangers.
The facility failed to ensure pharmacy recommendations were reviewed and signed by a physician for two residents. A pharmacist recommended medication reductions for both residents, but these were not addressed due to a lapse in the process after the former ADON left. The Medical Director and DON acknowledged the oversight, noting the expectation for recommendations to be addressed within 30 days.
A resident with intact cognition and specific dietary preferences was not receiving a sandwich with meals as documented on meal tickets. Despite the resident's requests and tray ticket instructions, observations confirmed the absence of the sandwich, which was acknowledged by the Dietary Manager.
A facility failed to implement proper infection control measures during a medication pass, as a CMT did not sanitize a blood pressure cuff before use on three residents and neglected hand hygiene before preparing medications for one resident. Staff interviews revealed inconsistencies in understanding cleaning protocols, with the DON confirming that equipment should be cleaned between each resident use.
A resident received antibiotic eye drops without a specified stop date following cataract surgery, leading to prolonged administration without medical necessity. Facility staff, including the LPN, DON, and IP, were unaware of the ongoing use, and the order was not included in the antibiotic tracking list, contrary to the facility's antibiotic stewardship policy.
The facility failed to provide a personalized dialysis contract for a resident with end-stage dialysis, despite physician orders for dialysis services. The resident was cognitively intact, and the facility was unable to locate the contract, waiting for a copy from the dialysis center. This deficiency could impact all residents receiving dialysis services.
A resident was discharged to a hospital following an unplanned emergency, but only a verbal discharge notice was given to the resident's guardian by the DON. No written discharge notice was found in the medical or hospital records, and staff interviews revealed uncertainty about who was responsible for ensuring written notification. The facility could not verify that the required written discharge notice was provided.
A resident was denied re-admission to the facility after a hospital stay that exceeded the bed-hold policy, despite being ready for discharge and multiple referral attempts by the hospital and the resident's guardian. The facility's administration and clinical team decided not to allow the resident back, citing inability to meet the resident's needs, and acknowledged this action was against regulatory requirements.
A facility's call light system malfunctioned, leading to significant delays in responding to residents' needs. A resident with a history of ventricular tachycardia and other conditions experienced a 20-minute delay in having their call light answered. The system only alerted at the nurse's station, and CAT phones were not in use, leaving staff unaware of activated call lights. Interviews revealed a lack of awareness and communication about the system's status, resulting in unmet expectations for timely responses.
A resident's dignity was compromised when a CNA pulled down their pants, exposing their buttocks to bystanders during an episode of aggression. The incident was captured on camera, and the resident, who was cognitively intact, felt embarrassed. The facility's dignity policy was not upheld, and the CNA involved was assigned to monitor the resident due to self-harming behaviors earlier that day.
The facility failed to manage the weight of two residents with PEG tubes, leading to discrepancies in weight records. One resident lost 21 pounds in 34 days without re-weighing or care plan updates, while another was not weighed for two months. Staff interviews revealed a lack of awareness and protocol for addressing weight changes, compounded by scale calibration issues.
A facility failed to properly manage and document tube feeding for a resident with a PEG tube. The resident, with conditions including paraplegia and dysphagia, did not have physician's orders for tube feeding intake, and there was no documentation on the MAR/TAR for two months. Observations showed the tube feeding bag was not changed every 24 hours, and the flush bag was unlabeled. Interviews revealed inconsistencies in staff understanding and documentation practices, with the ADON noting a possible issue with the resident's diet change affecting the order's presence on the TAR.
A bedbound resident with multiple medical conditions was found without an accessible call light, relying instead on a virtual assistant to call for help, which was ineffective. Staff acknowledged the issue, and the facility's new call light system was not fully operational, requiring staff to check a monitor for alerts.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse during an unwitnessed altercation. One resident with chronic pulmonary edema, end stage renal disease, congestive heart failure, chronic kidney disease, ADL self-care deficits, limitations in physical mobility, and moderate cognitive impairment reported that another resident entered the room via the shared bathroom and physically assaulted them. The resident stated that the other resident hit them an unknown number of times, including kicking the dialysis port and scratching the face, leading to significant pain and a request for hospital evaluation. The other resident involved had a history of CVA with hemiplegia, idiopathic peripheral autonomic neuropathy, congestive heart failure, muscle wasting and atrophy, and major depressive disorder, and was care planned as having potential for verbal and physical aggression. This resident initially wrote that the first resident entered their room through the bathroom and took cigarettes, prompting them to stand up and chase the first resident back to their room, where the first resident allegedly threw a walker, causing a fall. In a later interview, this resident admitted to punching the other resident three times because of the alleged theft of cigarettes, and reported losing balance and falling, resulting in right hip pain for about a day. Clinical documentation and hospital records confirmed injuries to the first resident, including a chest wall contusion and facial abrasion attributed to a physical assault, with pain levels documented as high as 8–9 out of 10 on subsequent shifts and treatment with oxycodone. A skin assessment noted a scratch with scab near the right nostril. The second resident reported right hip pain after the fall. Staff interviews confirmed that the incident was considered abuse, that it was unwitnessed and over before staff entered the room, and that the residents had engaged in a physical altercation resulting in injuries to both, demonstrating that the facility did not prevent resident-to-resident physical abuse as required by its abuse, neglect, and exploitation policy.
Failure to Maintain Functional Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the call light system operated as designed, that call lights were accessible to residents, and that call lights were answered in a timely manner, as required by facility policy and resident care plans. The facility’s written policy required a functioning call system at each bedside, toilet, and bathing area, with alerts either directly to staff or to a centralized location, and required staff to keep call lights within reach and respond promptly. Review of the Device Activity Report for one hall over several weeks showed an average call light response time of approximately 70 minutes, with many individual calls taking from over 20 minutes to many hours, including one documented response time of over 1,100 minutes. Staff interviews confirmed that there were no audible or visual hallway alerts, that staff relied solely on a computer screen at the nurse’s station, and that the sound on the system was often turned down. Multiple residents with significant mobility, respiratory, and ADL deficits reported prolonged waits for assistance and difficulty accessing call lights. One cognitively intact resident with hemiplegia, polyneuropathy, foot drop, generalized muscle weakness, unsteadiness, and a history of falls stated that call lights were sometimes not answered for hours, including waits of up to 5 hours, and reported having to call 911 from a cell phone because staff did not respond. Device Activity Reports for this resident documented several extended response times, including one of 350 minutes. Another cognitively intact resident with COPD, anxiety, and depression, on continuous oxygen, reported waiting up to 3 hours for call lights to be answered, including episodes where oxygen ran out and assistance was delayed until the next shift. A third cognitively intact resident with hemiplegia, COPD, acute respiratory failure with hypoxia, and a history of falls reported that staff took hours to answer call lights, that family and friends had to seek staff for help with shortness of air, and that there were times when no one came until the next shift; this resident also reported incontinence episodes because staff did not respond. Additional residents with significant physical and cognitive impairments experienced similar issues. One cognitively intact resident with hemiplegia, difficulty walking, muscle weakness, need for personal care assistance, and repeated falls reported waiting hours for call lights to be answered, sometimes being unable to reach the call light, and remaining in urine and/or bowel for hours before being changed; this resident was observed attempting to transfer from a wheelchair to bed without being able to reach the call light. A resident with severe cognitive impairment, COPD, dysphagia, incontinence, and continuous oxygen was observed in bed with the door closed, unable to reach the call light, coughing, choking on saliva, and short of breath; this resident reported often being unable to reach the call light, waiting hours for help, and lying in urine and bowel for hours when staff did not respond. Another resident with multiple sclerosis, muscle weakness, reduced mobility, hemiplegia, and need for total assistance reported that call lights were on for over 30 minutes and often for multiple hours, including one episode where a call light activated at about 1:00 a.m. was not answered until nearly 8:00 a.m., during which the resident lay in urine. During observation, this resident’s call light had been on for over 30 minutes with no hallway light or audible alert, while a CNA sat at the nurse’s station using a cell phone until prompted by another CNA to answer the light. Staff interviews corroborated that the call light system did not provide adequate audible or visual alerts and that response expectations were not met. A CNA stated that the call light system was broken, that staff only knew a call was active if they were looking at the computer screen at the nurse’s station, and that there were no lights above resident rooms or sounds in the hallways when call lights were activated. An RN reported that CNAs were expected to answer call lights within 10 minutes but that staff only knew about calls by looking at the nurse’s station screen, with no lights or sounds elsewhere, and acknowledged extended call light times. An LPN stated that policy required call lights to be answered within 10 minutes, that the computers at the nurse’s station were the only alert mechanism, and that the sound on the system was often turned down. These observations, interviews, and records demonstrate that the facility failed to maintain a functional, accessible call light system and failed to ensure timely staff response to call lights for multiple residents with significant ADL, mobility, and respiratory needs.
Failure to Monitor and Administer PRN Oxygen for Resident With COPD and Respiratory History
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen as ordered and to assess and monitor oxygen saturation levels and respiratory status for a resident with significant pulmonary diagnoses. The resident was readmitted with COPD, acute respiratory failure with hypoxia, and pneumonia, and had a care plan identifying potential for decline in respiratory status related to COPD exacerbations. The care plan interventions included administering medications and inhalers as ordered, monitoring for effectiveness and side effects, and monitoring and documenting changes such as increased restlessness, anxiety, air hunger, and signs and symptoms of respiratory distress to be reported to the physician. A physician’s progress note directed staff to monitor for recurrent respiratory symptoms, monitor oxygen saturation and respiratory rate, and assess the need for supplemental oxygen if clinically indicated. The resident had an active physician order for supplemental oxygen at 2 L/min via nasal cannula as needed for oxygen saturation less than 90% and/or wheezing and shortness of air. However, the Medication Administration Record for the entire month showed no documentation of oxygen administration and no oxygen saturation assessments; all opportunities for oxygen administration and oxygen saturation assessments were blank. The facility’s own oxygen administration and vital signs policies required that oxygen be administered under physician orders, that staff document initial and ongoing assessments and responses to oxygen therapy, and that oxygen saturation be assessed for residents requiring oxygen at intervals specified by the physician. The vital signs policy also identified oxygen saturation as a vital sign, with an acceptable range above 90%, and required vital signs when a resident’s general condition changed or when nonspecific symptoms of physical distress were reported. Interviews and observations further demonstrated that the resident’s respiratory needs and orders were not being implemented or monitored as required. The resident, who was cognitively intact, reported having pneumonia three times since admission, having oxygen ordered by the physician, experiencing shortness of air at night, and that staff did not check oxygen saturation levels. An oxygen saturation summary showed the resident’s oxygen saturation was assessed on one date in early September and not again until early March, indicating a long gap in monitoring. During observation, the resident stated they were not being administered oxygen, and there was no oxygen concentrator or portable oxygen tank in the room, despite the as-needed oxygen order and reported shortness of air. Staff interviews revealed inconsistent practices and lack of awareness of the resident’s respiratory orders and monitoring needs. An RN stated it was standard practice to obtain vitals once per month, acknowledged not always documenting vitals in the EMR, had not assessed the resident’s oxygen saturation level, did not know when it was last assessed, did not know if the resident had an oxygen concentrator, and was unaware of the resident’s respiratory assessment and monitoring orders, despite knowing the resident had COPD and recent pneumonia. A CMT reported the resident complained of shortness of air and that this was reported to the RN, but the CMT did not assess oxygen saturation and stated CMTs had no place to document oxygen saturation in the EMR and were not aware of the resident’s respiratory and oxygen orders because those appeared only on the nurse’s side of the EMR. CNAs reported that nurses or CMTs were responsible for vitals, that they did not know how to access care plans or resident-specific oxygen and monitoring orders, and that they did not monitor oxygen saturation levels. An LPN described a practice of checking oxygen saturation and administering oxygen if saturation was below 90%, but this was not reflected in the resident’s documentation. The Administrator/DON confirmed expectations that vitals be obtained monthly, that physician orders be followed, that respiratory assessments including vitals be completed when residents report shortness of air, and that residents with COPD have vitals and oxygen saturation monitored as needed, expectations that were not met in this resident’s case.
Failure to Provide Behavioral Health Services and Substance Use Care Planning Resulting in Resident Overdoses
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including assessment and care planning, for three residents with known substance use disorders, as required by facility policy and PASRR recommendations. The facility’s Illicit Drug and Alcohol policy and Behavioral Health Services policy required that residents with substance use disorders receive person-centered behavioral health assessments, care plans, and interventions, including care plans addressing illicit drug, marijuana, or alcohol use, increased monitoring when substance use was suspected, and access to substance abuse programming and supports. For Resident #3, the PASRR documented serious mental illness, polysubstance dependence, recent methamphetamine use, and recommendations for substance abuse programming such as community-based treatment, 12-step programs, and residential/intensive treatment. Despite this, the medical record contained no risk assessments related to substance use/abuse, no documentation of substance abuse programming or NA/AA resources, and no care plan problem, goal, or interventions addressing illicit substance use or the PASRR recommendations. The facility also failed to clearly define, document, and implement restrictions and monitoring measures it imposed on Resident #3 after repeated findings of drug paraphernalia. Progress notes documented that Resident #3 was found with illicit drug paraphernalia and was placed on a 30‑day restriction, later on supervised visitation and LOA restriction, and then on a 60‑day restriction with a 30‑day discharge notice. However, there was no documentation describing what these restrictions entailed, no clear staff instructions or education on how to implement them, and no assessment of the resident’s substance use needs or resources. The care plan referenced behavior problems with possession of illegal substances, restriction, re‑education on policy, and LOA restriction, but did not specify staff interventions for LOA or supervised visitation. Facility sign‑in/sign‑out sheets for multiple dates showed no records of visitor logs or resident sign‑outs, even though staff and administration stated that Resident #3 was supposed to have someone sign him/her out and show ID when leaving the building. For Residents #1 and #2, both had documented histories of substance use disorders and serious mental illness in their PASRRs, including alcohol dependence, cocaine dependence, polysubstance abuse, and a need for 24‑hour supervision and structured oversight to prevent relapse. Resident #1’s PASRR and admission information reflected alcohol dependence, chronic psychiatric conditions, and the need for around‑the‑clock nursing care, while Resident #2’s PASRR documented recent substance use, polysubstance abuse, and a requirement for continuous protective oversight. Despite these histories, neither resident had risk assessments related to substance use/abuse, and their care plans lacked any focus, goals, or interventions addressing alcohol or other substance dependence. There was also no documentation of NA/AA resources, education, or attendance for either resident. These failures in assessment, care planning, and implementation of behavioral health and substance use interventions preceded an incident in which Resident #3, who had a known history of polysubstance abuse and was on restriction, obtained fentanyl and used it in his/her room. According to the facility’s Suspected Abuse Investigation and nursing notes, on the evening in question Resident #3 was actively using a substance in his/her room when Residents #1 and #2 entered. Resident #3 told them to take a hit of the illicit substance, Resident #2 held the foil, and both Residents #1 and #2 used the substance and then became unconscious. Resident #3 later went to the nurses’ station requesting Narcan, and staff found one resident unresponsive in a wheelchair and the other unresponsive on the floor, both with pulses but not responding. LPNs administered Narcan to both residents, who responded after second doses, and EMS transported them to the hospital. Hospital records for Resident #1 documented an admission for overdose, with a history that he/she had been smoking fentanyl with another resident, accidentally overdosed, and was found unresponsive, and that he/she had never used fentanyl before but wanted to experience the high. Hospital records for Resident #2 documented an admission for pulmonary edema and drug overdose, with a history of polysubstance abuse and current use of liquor, cocaine, methamphetamines, and fentanyl, and that he/she reported planning to smoke methamphetamines with a friend but instead was given fentanyl and overdosed. Interviews with Residents #1 and #2 confirmed that they smoked what they believed to be methamphetamine with Resident #3, later learned it was fentanyl, and lost consciousness. Interviews with staff and residents also confirmed that Resident #3 had been on restriction due to prior paraphernalia findings, that staff did not search residents on return from LOA, that sign‑out procedures were not consistently documented, and that there was no special monitoring beyond the expectation that someone sign the resident out, which was not reflected in the facility’s sign‑in/sign‑out records.
Failure to Properly Notify Guardian After Resident Fentanyl Overdose and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court‑appointed guardian in a timely and effective manner after the resident overdosed on fentanyl, required emergency treatment, and was sent to the hospital. The resident had diagnoses including paranoid schizophrenia, bipolar disorder, and a history of traumatic brain injury, and had a court‑appointed guardian whose phone number, email, and address were listed in the admission record. On the date of the incident, progress notes documented that Narcan nasal spray was administered at 6:48 p.m. and again at 6:53 p.m., after which the resident took a deep breath, and the guardian was documented as notified at 6:58 p.m. The facility’s suspected abuse investigation documented that at approximately 6:40 p.m. the resident overdosed on an illicit substance, received two doses of Narcan, became alert and oriented, and was transported by ambulance to the hospital for further evaluation. Agencies notified were listed as the Department of Health and Senior Services, the provider, and the resident’s guardian. However, subsequent email communications showed that when the Social Services Director later emailed the guardian about an appointment, the guardian responded that the resident had personally informed the guardian about being sent to the hospital for a fentanyl overdose and that no one from the facility had contacted the guardian’s emergency cell or any deputy to report the overdose or hospital transfer. The guardian reported that only a voicemail had been left on the office line in the evening, with no indication that a return call was needed, and that there was no follow‑up contact from the facility the following day. The Administrator and DON later acknowledged that the nurse on duty had called a number and left a voicemail, but it was not the emergency number, and that the nurse had been unable to locate the emergency number at the time. The DON stated that leaving a voicemail was considered a notification and that the original public administrator was the only emergency number listed, while the guardian stated that multiple emergency contact options, including an emergency cell and a main switchboard, had been provided previously. These actions and omissions resulted in the guardian not being promptly and effectively notified of the resident’s fentanyl overdose and transfer to the hospital, contrary to the facility’s notification policy requiring prompt notification of the resident’s representative for significant changes in condition and transfers.
Failure to Implement Effective Pest Control Measures
Penalty
Summary
The facility failed to implement and maintain an effective pest control program as required by its own policy and as recommended by the pest control technician. Multiple pest control service invoices over several months documented repeated findings of rodent activity both inside and outside the building, including in resident rooms, the medication room, and common areas. The pest control technician consistently identified structural deficiencies such as holes in resident rooms, gaps under exterior doors, misaligned door frames, and cracks in walls and floors, all of which created potential entry points for rodents. Despite these findings, the facility did not address the technician's recommendations, such as sealing holes, repairing doors, and moving dumpsters further from the building. Observations during an environmental tour confirmed the presence of numerous unsealed holes and cracks in resident rooms, hallways, and exterior areas. Mouse droppings, glue traps, and direct sightings of mice were noted in several resident rooms and common areas. Residents reported frequent encounters with mice, including mice running in rooms, being caught in traps, and eating through personal food items. Staff interviews corroborated these observations, with housekeepers and CNAs reporting regular findings of mouse droppings, especially in rooms where food was stored, and documenting pest issues in the pest control log. The facility's Room Readiness checklists did not document the presence of wall holes in resident rooms, and maintenance staff acknowledged that pest control recommendations had not been prioritized or fully addressed. The maintenance director cited challenges such as the age of the building, misaligned door frames, and difficulties in moving dumpsters due to yard terrain. The administrator confirmed that pest control issues had not been the facility's top priority, and that protocols for regular room checks were only recently initiated. As a result, the facility failed to take aggressive and timely measures to prevent or minimize rodent infestation, potentially affecting all residents.
Failure to Transcribe and Clarify Opioid Pain Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to correctly transcribe and clarify physician orders for an opioid pain medication for a resident admitted with frostbite and necrosis of the left foot, as well as a non-pressure chronic wound. The hospital discharge instructions specified an order for Oxycodone 5 mg every six hours as needed for severe pain, but the facility's physician order sheet listed Oxycodone-Acetaminophen 2.5 mg-325 mg instead. This discrepancy led to the medication not being received from the pharmacy, and the resident did not receive the prescribed opioid pain medication. The resident's medication administration record showed that the ordered opioid medication was not administered because it was not received from the pharmacy. Nursing staff provided alternative non-opioid pain medications, and documentation indicated that the resident's pain was controlled during the day, though the resident reported increased pain at night. The resident did not request pain medication during the night shift and did not notify staff of uncontrolled pain at that time. Interviews with nursing staff and the DON revealed that the facility did not have an emergency medication kit for new admissions or medication changes, and there was a lack of follow-up and documentation regarding attempts to obtain the opioid medication. The pharmacy required a written or electronic prescription from the physician, which was not initially provided, and the discrepancy in dosage further delayed the process. The physician was not made aware that the resident had not received the prescribed medication until several days after admission.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a serious altercation between two residents. One resident, who had a history of paranoid schizophrenia and generalized anxiety disorder and was moderately cognitively impaired, was attacked by another resident who was cognitively intact and had diagnoses including psychoactive substance abuse, liver cell carcinoma, and adjustment disorder with anxiety. The aggressor followed the victim into a vending machine room, approached from behind, and struck the victim multiple times on the head with a solid wood and metal cane, causing a laceration that required stitches, bruising to the eye socket, and defensive injuries to the fingers. The incident was captured on facility video, which showed the aggressor holding the cane in a batting position and striking the victim without provocation. Witnesses and interviews confirmed that the victim did not engage with the aggressor prior to the attack and attempted to defend themselves only after being struck. The victim expressed fear of the aggressor and reported pain and difficulty using the injured fingers. The aggressor admitted to intentionally hitting the victim and stated this was a deliberate act, despite initially providing conflicting accounts of the event. Facility records and interviews indicated there were no prior documented conflicts or behavioral indicators between the two residents that would have predicted the assault. Staff were not alarmed by the aggressor's behavior prior to the incident, and the cane used in the attack was not previously seen with the aggressor. The facility's policies required ongoing assessment and monitoring of residents with behaviors that might lead to conflict, but these measures did not prevent the incident. The event resulted in significant physical harm to the victim and required intervention by law enforcement and medical personnel.
Excessively Low Weekend Staffing Levels
Penalty
Summary
The facility reported excessively low weekend staffing levels to the Centers for Medicare and Medicaid Services (CMS) through the mandatory submission of staffing information in the Payroll-Based Journal (PBJ). This deficiency had the potential to impact 112 residents by not providing the necessary care and services required. The facility's policy on nursing services and sufficient staff emphasizes the need to provide adequate staffing with appropriate competencies to ensure resident safety and well-being, considering the facility's census, acuity, and resident diagnoses. However, the staffing data report for the third and fourth quarters of 2024 indicated excessively low weekend staffing, with the facility receiving a one-star staffing rating. Interviews with facility staff revealed ongoing challenges in meeting staffing needs, particularly on weekends. The Staffing Coordinator/Human Resources (SC/HR) acknowledged the difficulty in maintaining adequate staffing levels, citing issues with staff not showing up despite continuous hiring efforts. Similarly, the Director of Nursing (DON) confirmed the challenges in scheduling and covering weekend shifts. These staffing deficiencies were documented through interviews and policy reviews, highlighting the facility's struggle to comply with its own staffing policy and the potential impact on resident care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours per day, as required by regulations. This deficiency was identified through the facility's mandatory submission of staffing information to the Centers for Medicare and Medicaid Services (CMS) via the Payroll-Based Journal (PBJ). The report indicated that there were no RN hours recorded for three out of four quarters in 2024, specifically the first, second, and fourth quarters. This lack of RN coverage had the potential to impact the care and services provided to 112 residents. Interviews conducted during the investigation revealed challenges in staffing. The Staffing Coordinator/Human Resources (SC/HR) acknowledged difficulties in hiring RNs for the night shift, despite efforts to recruit through various channels such as newspapers, media sites, and the facility's website. The Director of Nursing (DON) confirmed the absence of RN coverage for the specified quarters, corroborating the findings from the PBJ reports. The facility's policy on nursing services emphasized the importance of sufficient staffing to ensure resident safety and well-being, yet the facility failed to meet this standard during the identified periods.
Deficiency in Dietary Management and Food Service
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) or other qualified professional to manage the dietary department in the absence of a full-time Registered Dietitian. This deficiency was identified through observation, interviews, and document reviews. The Dietary Manager (DM) admitted to not having completed a certification course for dietary managers or any formal training in food or nutrition services, having assumed the role after working as a cook for two years. The facility also failed to ensure that food was palatable and served at appetizing temperatures, as evidenced by consistent complaints in the Resident Council Meeting Minutes over five months. Additionally, the facility did not honor a resident's preference for a sandwich to be included in lunch and dinner meals. Furthermore, the facility did not maintain sanitary conditions for food storage, preparation, and distribution, as confirmed by the Director of Nursing (DON), who acknowledged that the DM did not meet the necessary criteria.
Sanitation Deficiencies in Food Handling and Service
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and distribution, potentially affecting all 112 residents who consumed food from the kitchen. During an inspection, the handwashing sink in the kitchen was found to provide only cold water, not meeting the FDA's recommended temperature of 85 degrees Fahrenheit. Additionally, several pieces of kitchen equipment, including a food processor, can opener, juice dispenser, and microwave, were observed to be soiled with food residue and not properly cleaned. The walk-in refrigerator contained undated and unlabeled food items, such as health shakes and cooked pork loins, which were not stored according to the facility's policy. Staff practices further contributed to the unsanitary conditions. A dietary aide was observed handling clean water pitchers with the same gloves used for soiled dishes, and did not properly wash hands with soap and friction as required. During meal service, the Assistant Dietary Manager failed to record temperatures for certain food items, which were later found to be below the safe temperature range, necessitating reheating. On another occasion, food items on the tray line were also found to be held at unsafe temperatures and required reheating. The delivery of meal trays to residents' rooms was also problematic, as desserts were served uncovered, exposing them to potential contamination. This occurred on multiple occasions, with staff, including the Director of Nursing, acknowledging the issue. The lack of proper food covering during transport and the use of an uncovered cart further compromised the sanitary conditions of the meals served to residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of refuse and garbage, as observed by surveyors. During multiple observations on different dates, the lid of the dumpster located behind the kitchen was found open. This was confirmed through an interview with the Dietary Manager, who stated that all departments in the facility were responsible for discarding garbage in this area and were expected to close the lid after use. The open dumpster lid had the potential to increase the risk of rodents and other pests, which could affect all 112 residents residing at the facility.
Facility Lacks QAPI Plan for Resident Care Improvement
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that outlines the process for guiding care and services provided to residents and measuring improvement. This deficiency was identified during a survey when the Director of Nursing (DON) and the Administrator were unable to provide a QAPI plan upon request. The facility's policy, revised in March 2020, states that the QAPI program is overseen by a committee that reports to the administrator and governing body. However, the Administrator, who was new as of January 2025, admitted to not knowing what a QAPI plan is and confirmed that the facility did not have one. The DON mentioned that there had only been one meeting with staff regarding clinical pathways, but no specific improvement programs were identified, and previous meeting records with the former Administrator could not be found. This lack of a QAPI plan had the potential to impact the care and services for 112 residents.
Facility Fails to Address Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances repeatedly voiced by the Resident Council, which included concerns about food palatability, staff-to-resident interactions, pest control, and call light response times. During a group meeting, residents expressed dissatisfaction with the temperature of food served in their rooms, noting it was often cold. They also reported issues with staff being distracted by personal activities, such as using cell phones, and a persistent mouse problem within the facility. The Resident Council minutes from September 2024 through February 2025 documented these concerns repeatedly, yet no actions were taken to address them. The minutes highlighted ongoing issues with cold food, rude staff interactions, mouse sightings, and delayed call light responses. Despite these documented grievances, the facility did not provide any follow-up or resolution to the council, leading to feelings of being ignored among the residents. Interviews with residents, including the Resident Council President, confirmed that their concerns were not acted upon, and no resolutions were presented. The Director of Nursing acknowledged the lack of grievance forms or resolutions related to these issues and admitted that no actions had been taken to address the residents' concerns. The facility's policies on Resident Council and grievance handling were not followed, as no tracking or corrective actions were implemented.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving four residents. Resident 52, who was cognitively intact, reported being hit by their former roommate, Resident 26, who had a diagnosis of vascular dementia and a history of physical aggression. The altercation was not witnessed, but the police were called, and both residents were separated. Resident 26's care plan included interventions for managing aggressive behavior, but the incident still occurred. Another incident involved Resident 31 and Resident 24. Resident 24, who had mild cognitive impairment and a history of physical and verbal behavioral symptoms, approached Resident 31 in the dining room and grabbed their arm. Staff intervened, but Resident 24 struck a staff member while being wheeled away. Resident 31, who was cognitively intact, later reported feeling that the interactions with Resident 24 were abusive, as Resident 24 continued to approach them aggressively in subsequent encounters. The facility's policy on abuse prevention emphasizes protecting residents from abuse by anyone, including other residents. However, the incidents involving Residents 52, 26, 31, and 24 indicate a failure to effectively implement this policy, as evidenced by the repeated altercations and the residents' feelings of being unsafe. The facility's administrator acknowledged that resident-to-resident altercations could be considered abusive if there was intent to harm, but the investigation into these incidents did not consistently recognize them as abuse.
Failure to Report Resident Altercations
Penalty
Summary
The facility failed to implement policies and procedures for reporting suspected abuse, neglect, or theft in accordance with section 1150B of the Act. This deficiency was identified for four residents during a review of abuse cases. The facility did not report incidents involving resident-to-resident altercations to the state survey agency (SSA) within the required timeframe. For instance, an altercation between two residents, where one resident punched the other, was not reported to the SSA within two hours as required for abuse occurrences. In another case, a resident reported having issues with another resident, which led to a physical altercation in the dining room. The incident involved one resident grabbing and striking another resident's arm, as well as hitting a staff member. Despite these events, the facility's Administrator did not report the incidents to the SSA, citing that neither resident felt threatened or scared. This lack of reporting was contrary to the facility's policy, which mandates immediate reporting of such incidents. The facility's policies on abuse, neglect, exploitation, and misappropriation require that any allegations be investigated and reported within specific timeframes. However, the facility failed to adhere to these policies, as evidenced by the unreported incidents involving the residents. The Administrator, who is responsible for reporting abuse, did not fulfill this obligation, resulting in a deficiency in the facility's compliance with federal requirements.
Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of resident-to-resident abuse involving four residents. One incident involved a resident with intact cognition who allegedly hit another resident with moderately impaired cognition. The facility's incident report noted physical aggression, but there was no evidence of an investigation, including statements from the involved residents or interviews with staff and other residents. The administrator acknowledged the lack of investigation and stated it should have been conducted thoroughly. Another incident involved a resident with moderately impaired cognitive capabilities who allegedly grabbed and struck another resident with intact cognitive ability. The Director of Nursing initially claimed the investigation was complete, but upon further questioning, it was revealed that essential components such as witness statements and root cause analysis were missing. The investigation documents were only printed on the day the investigation was requested, indicating a lack of timely and thorough investigation. The facility's policy on abuse prevention and investigation requires a comprehensive approach, including reviewing documentation, interviewing involved parties, and observing interactions. However, the facility did not adhere to these guidelines, as evidenced by the incomplete investigations and lack of documentation. The administrator's statement that the incident was not considered abuse because neither resident felt threatened further highlights the facility's failure to follow its own policies and federal requirements for investigating and reporting abuse allegations.
Documentation Discrepancies in Narcotic Administration
Penalty
Summary
The facility failed to ensure that the electronic medication administration record (MAR) matched the Controlled Drug Administration Record Tablet for three residents, leading to discrepancies in the documentation of administered narcotic medications. Resident 65, who was admitted with a diagnosis of chronic pain syndrome, experienced multiple instances where doses of oxycodone and buprenorphine were not documented on the MAR despite being administered. This inconsistency was observed over several days, with some doses not being recorded at all, and others being out of stock, increasing the risk of medication errors. Similarly, Resident 97, admitted with chronic pain, had several doses of oxycodone not documented on the MAR, despite being administered according to the Controlled Drug Administration Record. The discrepancies occurred on multiple occasions, indicating a pattern of incomplete documentation. Resident 86, with diagnoses including abdominal pain and neuropathy, also had numerous instances where doses of oxycodone were not recorded on the MAR, despite being administered as per the Controlled Drug Administration Record. Interviews with facility staff, including an LPN and an RN, revealed that while narcotics were documented on the paper narcotics log, they were not consistently recorded in the electronic MAR. The Director of Nursing confirmed that the EMR is the required administration record and that all medications should be documented there when administered. The facility's policies on controlled substances and medication administration emphasize the importance of accurate documentation, which was not adhered to in these cases.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store medications, specifically insulin pens, on two medication carts. During an observation, it was found that two Humalog insulin pens were not labeled with the resident's name, and five Lantus insulin pens were open and not dated. Additionally, a Levemir insulin pen and a Lantus vial were found with expired open dates. Personal items such as lipstick and makeup, as well as food items like applesauce, were improperly stored with medications. The LPN responsible for the cart confirmed the pens were opened and used. In another observation, three insulin pens were opened and not dated, and a bottle of liquid Gabapentin oral solution was also opened without a date. Personal items, including a purse and cell phone, were found stored with patient medications, along with two containers of pudding. Two bottles of sterile water were found to be expired. The RN acknowledged that food should not be stored with medications and that liquids need to be dated when opened. The Director of Nursing confirmed that insulin pens should be labeled with the resident's name and dated when opened, and that food and personal items should not be stored in medication carts.
Facility Fails to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for all residents reviewed for food concerns. During a meal service observation, the temperatures of the food items were recorded between 170 and 190 degrees Fahrenheit before tray service. However, a test tray revealed that the food temperatures were significantly lower when served, with chicken parmesan at 123 degrees F, creamy rice at 121 degrees F, and broccoli at 110 degrees F, which affected the palatability of the food. The Dietary Manager confirmed that the temperatures impacted the taste of the food. Interviews with multiple residents revealed consistent complaints about the food being served cold and unappetizing. Residents expressed dissatisfaction with the taste and appearance of the meals, and some noted that they were not allowed to use microwaves to reheat their food. Additionally, the Resident Council Meeting Minutes indicated ongoing grievances related to food palatability over five months, which the facility failed to address adequately. This lack of action placed all residents at risk for weight loss due to unpalatable meals.
Failure to Inform Residents of Arbitration Agreement Conditions
Penalty
Summary
The facility failed to inform 29 residents and/or their representatives that signing a binding arbitration agreement was not a condition for admission or continued care. This oversight was identified through interviews, record reviews, and policy reviews. The facility's Arbitration Agreement Rider to the Admission Contract did not include a statement clarifying that residents or their representatives were not required to sign the agreement as a condition of admission. This omission placed the residents at risk of signing the agreement involuntarily. During an interview, the Admissions Coordinator confirmed that the arbitration agreement lacked the necessary statement and acknowledged that residents were not required to sign the agreement upon admission, despite the form not having a section to decline. The facility's policy on binding arbitration agreements also stipulated that the agreement must explicitly state that signing was not a condition for admission or continued care, which was not adhered to in practice.
Failure to Inform Residents of Right to Neutral Arbitrator
Penalty
Summary
The facility failed to inform 29 residents and/or their representatives about their right to select a neutral arbitrator agreed upon by both parties when signing a binding arbitration agreement. This oversight was identified through interviews, record reviews, and policy reviews conducted by the survey team. The facility's Arbitration Agreement Rider to the Admission Contract did not include provisions for the selection of a neutral arbitrator, which is a requirement according to the facility's own policy on binding arbitration agreements. During the investigation, it was revealed that the facility's Admissions Coordinator acknowledged the absence of this provision in the arbitration agreement. The undated document titled 'Signed & Uploaded Arbitration Agreements' confirmed that 29 residents had entered into these agreements without being informed of their right to a mutually agreed-upon neutral arbitrator. This deficiency placed these residents at risk of misunderstanding the arbitration process.
Failure to Offer Pneumococcal Vaccination to Residents
Penalty
Summary
The facility failed to ensure that five residents were assessed for eligibility, educated on the risks and benefits, and offered the pneumococcal vaccination. This deficiency was identified during a review of the medical records and interviews with the Infection Preventionist (IP). The IP, who had recently taken over the position, acknowledged that there was no documentation of offering, refusal, or administration of the pneumococcal vaccine for these residents. The residents involved had various medical conditions, including paraplegia, vascular disorders, peripheral vascular disease, heart disease, acute respiratory failure, and congestive heart failure. The facility's policy, dated October 2019, required that all residents be offered the pneumococcal vaccine to prevent pneumonia and pneumococcal infections. The policy stipulated that assessments of vaccination status should be conducted within five working days of admission, and the vaccine should be offered within thirty days unless contraindicated or previously administered. However, the review revealed that there was no historical documentation of the vaccine being offered or administered to the residents in question, placing them at risk for contracting pneumonia unnecessarily.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for several residents, as evidenced by multiple maintenance issues observed in six rooms. The Regional Maintenance Consultant (RMC), who was recently hired, acknowledged the presence of walls in disrepair, broken heating vents, and light fixtures, among other issues. The facility had implemented a new reporting program through their electronic medical records (EMR) system for staff to report maintenance needs, but it had only been used a few times. The RMC noted that the Maintenance Director, who had been at the facility for about a year and a half, required training on time management and prioritization. In one instance, a resident with intact cognition expressed discomfort due to the poor condition of the walls in their room, which were covered with screws, nails, chipped paint, and discolored patches. Another resident, also with intact cognition, reported the absence of a mirror in their bathroom, requiring them to walk to the shower room to see themselves. This room also had multiple small holes and unpainted patches on the walls. Additionally, the door exiting to the smoking area had a baseboard that was peeling off, exposing crumbling concrete and dirt, which the RMC confirmed could potentially allow pest access. Two residents reported a lack of heat in their room throughout the winter, forcing them to wear additional clothing for warmth. They were offered a room change, which they declined, and noted that the facility had promised to replace the heater. Their bathroom also had a ceiling vent with the cover off, holes in ceiling tiles, and walls. Other rooms had issues such as a heater cover sitting on the floor, a broken mirror, closet doors off hinges, and a broken light cover hanging over a resident's bed. The facility's policy on maintaining a safe and homelike environment was not adhered to, as these maintenance issues were not promptly addressed or reported to the Administrator as required.
Facility Fails to Address Mouse Infestation
Penalty
Summary
The facility failed to implement effective pest control measures to prevent a mouse infestation, affecting four residents and common areas. Weekly pest control service inspection reports from March 2024 to December 2024 documented ongoing treatment for mice and repeated recommendations to prevent their entry. These recommendations included fixing holes near heat registers and baseboards, rodent-proofing kitchen doors, eliminating gaps under the front door, and removing trash around the facility. Despite these recommendations, the facility did not address the issues, leading to continued rodent activity. The pest control service inspection report from January 2025 confirmed evidence of rodent activity and recorded captures. It highlighted open conditions such as a gap under the kitchen exterior entryway door sweep, trash and debris near the back door, and the need for rodent-proofing of the kitchen and front doors. These conditions were marked as high severity, with the responsibility for correction assigned to the facility. The facility's failure to act on these recommendations resulted in ongoing rodent presence. Interviews with residents revealed their distress over the mouse infestation. One resident reported seeing mice in the hall and having mouse traps in their room, while another found mouse droppings behind their nightstand and experienced mice running over their feet at night. A third resident discovered a dead mouse in their room, and a fourth found mice eating their food. The Regional Maintenance Consultant acknowledged that the facility had not addressed the pest control recommendations and noted the Maintenance Director's need for training in time management and prioritization.
Failure to Respect Residents' Rights and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to privacy, dignity, and autonomy, affecting three residents. One resident, with intact cognition, experienced a breach of privacy when a housekeeping staff member entered the room without knocking, which the resident found bothersome and potentially harmful. Additionally, staff were observed speaking loudly and using inappropriate language in common areas, which disrupted another resident's privacy during a phone call. This resident also reported that the noise and language were disrespectful, and the Social Services Director was unaware of these issues. Another resident, also with intact cognition, expressed a desire not to have a meal tray left in their room, as it would not be picked up promptly. Despite the resident's repeated refusals, the Social Services Director left the tray, citing a need to offer meals, although the Director of Nursing later clarified that residents' rights to refuse meals should be respected. These incidents highlight a failure to respect residents' choices and privacy, as well as a lack of communication and awareness among staff regarding residents' rights and facility policies.
Failure to Provide Correct SNFABN Forms to Residents
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055, to residents whose Medicare Part A services were no longer covered or whose coverage was ending. This deficiency was identified for three residents. For two residents, R61 and R114, there was no documentation or evidence that the SNFABN form was provided, and no communication was recorded in their electronic medical records regarding potential additional costs if they chose to continue receiving services. For the third resident, R110, although a form was provided, it was the incorrect and expired version of the SNFABN form. During an interview, the Social Service Director (SSD) acknowledged the oversight, stating that they were unaware of the requirement to provide the correct form and did not notice the expiration of the form given to R110. The SSD confirmed that the forms should have been provided and that copies should have been available. This lack of proper notification had the potential to prevent residents from making informed decisions about their care and financial responsibilities.
Inaccurate Weight Assessment Leads to Unreported Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's weight and significant weight loss. The resident, who was admitted with multiple medical conditions including acute kidney failure, chronic kidney disease, and type 1 diabetes mellitus, experienced a significant weight loss of 7.88% over one month. However, the quarterly Minimum Data Set (MDS) assessment inaccurately recorded the resident's weight as 195 pounds, failing to reflect the actual weight of 177.8 pounds, which should have been noted as a significant weight loss. Interviews revealed that the Dietary Manager (DM) was responsible for completing the Nutrition and Weight section of the MDS and should have used the most recent weight. The MDS Coordinator confirmed that the weight loss met the criteria for significant weight loss and should have been coded on the MDS. The DM was unaware of the significant weight loss and could not explain the discrepancy in the recorded weight. The facility's policy on conducting accurate resident assessments emphasizes the importance of correctly documenting medical and functional problems, which was not adhered to in this case.
Failure to Complete PASARR Level I Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure the completion of a Pre-Admission Screening and Resident Review (PASARR) Level I screening for a resident with mental disorders, which is a requirement prior to admission. The resident, identified as R36, was admitted with diagnoses including major depressive disorder, schizoaffective disorder, post-traumatic stress disorder (PTSD), and substance abuse issues. Despite these significant mental health diagnoses, there was no evidence of a completed PASARR Level I screening in the resident's electronic medical record (EMR), which is necessary to determine the appropriateness of admission by the State mental health authority. During an interview, the Social Service Director (SSD) confirmed the absence of the PASARR Level I screening for the resident and acknowledged that it should have been completed and available in the EMR before admission. The facility's policy mandates that all applicants be screened for serious mental disorders or intellectual disabilities in accordance with State Medicaid rules, and a record of this pre-screening should be maintained in the resident's medical record. The failure to complete this screening could result in the resident residing in the facility without the necessary determination of appropriateness for admission.
Failure to Implement Safety Interventions for Residents with Substance Use Disorders
Penalty
Summary
The facility failed to develop and implement safety interventions for two residents with substance use disorders, leading to deficiencies in care. Resident 2 was admitted with diagnoses including anxiety, nicotine dependence, PTSD, alcohol abuse, and bipolar disorder. Despite testing positive for fentanyl and being implicated in providing drugs to other residents, the resident's care plan did not address their history of substance abuse or include interventions to prevent substance use within the facility. The Director of Nursing was unable to find any incident report or investigation related to the resident's substance use. Resident 32, admitted with chronic obstructive pulmonary disease, anxiety, alcohol dependence, and major depression, was found with decreased level of consciousness and tested positive for fentanyl, morphine, and suboxone. The resident was hospitalized for an opioid overdose, and it was suspected that they obtained drugs from another resident. Similar to Resident 2, Resident 32's care plan did not address their history of substance abuse or include necessary interventions for monitoring and prevention of substance use. Interviews with facility staff, including the Director of Nursing and Social Services Director, revealed an expectation for care plans to address residents' substance use disorders and include interventions such as increased monitoring, drug screening, and participation in cessation groups. The facility's policy on safety for residents with substance use disorders was not effectively implemented, as evidenced by the lack of care plan interventions for both residents.
Unsafe Storage and Unsanitary Conditions of Oxygen Equipment
Penalty
Summary
The facility failed to ensure the safe storage of portable compressed oxygen cylinders, as observed during a survey. Three oxygen cylinders were found not secured in a stand or attached to medical equipment designed to hold compressed gas cylinders. One cylinder was observed in front of the East Nurses Station, free-standing and with oxygen tubing lying on the floor, while another was found in the oxygen storage room, also unsecured. Staff interviews revealed a lack of awareness regarding the proper storage of these cylinders, with an LPN acknowledging the risk of explosion if a cylinder were to be knocked over. Additionally, the facility did not maintain respiratory equipment in a clean and sanitary manner for a resident using supplemental oxygen. The resident's oxygen tubing was found lying directly on the floor with two different dates marked on it, and the humidifier bottle was dated over three weeks prior. The oxygen concentrator filter was heavily coated with gray dust. An LPN confirmed that the tubing should not be on the floor due to contamination risks and that the equipment should be changed weekly, but the tubing was not dated to indicate when it was last changed. The facility's policies on oxygen safety were not adhered to, as evidenced by the unsecured oxygen cylinders and the unsanitary condition of the respiratory equipment. Interviews with staff, including an RN and the DON, highlighted the potential dangers of leaving oxygen cylinders free-standing, such as the risk of explosion or the cylinder becoming a projectile if the gauge were to break. The deficiencies observed pose a significant risk to the safety and well-being of residents and staff.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and signed by the physician for two residents, R19 and R60. R19's electronic medical record showed that the resident was admitted with diagnoses of major depression and anxiety. The pharmacist recommended a reduction in clonazepam and doxepin on 07/24/24 and sertraline on 12/23/24, but there was no response from the physician. R60's record indicated diagnoses of anxiety and major depressive disorder, with a recommendation from the pharmacist to consider a trial reduction of Ativan on 3/21/24 and 09/23/24, which also went unaddressed by the physician. Interviews revealed that the facility's process for handling pharmacy recommendations was disrupted after the departure of the former Assistant Director of Nursing (ADON), who previously managed these reviews. The Medical Director stated that recommendations, especially those concerning psychotropic medications, were typically addressed by a psychologist or nurse practitioner, with an expectation of being addressed within 30 days. However, the Director of Nursing (DON) confirmed that after the former ADON left, the facility could not locate the recommendations, leading to the oversight.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically the inclusion of a sandwich with lunch and dinner meals, as documented on the resident's meal tickets. The resident, who was admitted with diagnoses including peripheral vascular disease, heart disease, and amputation of toes, had a BIMS score indicating intact cognition. Despite the resident's clear preference and the documentation on the meal tickets, the resident consistently did not receive the requested sandwich with meals. Observations and interviews confirmed the deficiency. On multiple occasions, the resident received meals without the requested sandwich, despite the tray tickets indicating that a sandwich should be included. The Dietary Manager acknowledged noticing that the resident was not receiving sandwiches as per the tray ticket instructions. This oversight in meal service could potentially impact the resident's nutritional intake, as the resident expressed that the regular meals were insufficient without the additional sandwich.
Infection Control Lapses During Medication Pass
Penalty
Summary
The facility failed to implement effective infection prevention strategies during a medication pass, as observed with three residents out of a sample of 27. Specifically, a Certified Medication Technician (CMT6) did not sanitize the blood pressure cuff before taking the blood pressure of three residents. Additionally, during medication administration, CMT6 did not perform handwashing or hand hygiene before preparing medications for one of the residents. Interviews with staff revealed inconsistencies in understanding the protocol for cleaning equipment, with the Registered Nurse (RN) stating that blood pressure cuffs should be cleaned after each use, while CMT6 initially believed it was after every 4-5 residents. The Director of Nursing (DON) confirmed that vital signs equipment should be cleaned between every resident use and that hands should be sanitized between each resident contact.
Failure to Specify Duration of Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that a resident's antibiotic therapy had a specified duration and did not continue without medical necessity. The resident, who was admitted with a diagnosis of chronic obstructive pulmonary disease, received Ofloxacin Ophthalmic Solution, an antibiotic eye drop, following cataract surgery. The physician's order for the antibiotic eye drops did not include a stop date, and the medication was administered from January 10, 2024, to February 18, 2025, without reassessment of its necessity. Interviews with facility staff revealed a lack of awareness and oversight regarding the continuation of the antibiotic therapy. The LPN confirmed the absence of a stop date in the order, and the DON acknowledged the need to contact the resident's physician for clarification. The Medical Director stated that the order should have included a stop date, as the eye drops are typically used only for several weeks post-surgery. The Infection Preventionist was unaware of the ongoing administration of the antibiotic and noted that it should have been included in the facility's antibiotic tracking list, which it was not. The facility's antibiotic stewardship policy requires that all antibiotic orders include a start and stop date, which was not adhered to in this case.
Failure to Provide Dialysis Contract for Resident
Penalty
Summary
The facility failed to provide a personalized dialysis contract for a resident, identified as R31, who required dialysis services. R31 was admitted with a diagnosis of end-stage dialysis and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident's electronic medical record (EMR) included physician orders for dialysis at the facility on specific days of the week. However, upon review, it was found that the facility did not have a signed dialysis contract in place for R31. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility was unable to locate the dialysis contract and was waiting for a copy from the dialysis center. Despite multiple requests, the facility confirmed that they had not received the necessary contract from the dialysis center. This deficiency in maintaining a dialysis contract had the potential to affect all residents receiving dialysis services at the facility.
Failure to Provide Written Discharge Notice After Emergency Transfer
Penalty
Summary
The facility failed to provide a written discharge notice to a resident and their guardian upon the resident's unplanned emergency discharge. The resident called Emergency Medical Services (EMS) and was transported to a local hospital. Documentation showed that only a verbal emergency discharge notice was given to the resident's guardian by the Director of Nursing (DON), with the intention to fax a written notice during business hours the following day. However, there was no evidence in the resident's electronic medical record or hospital records that a written discharge notice was ever provided. The resident's care plan did not include any discharge planning, and the guardian was unsure if a written notice had been received, with no record of it available. Interviews with facility staff revealed confusion regarding responsibility for completing and providing written discharge notices. The DON and acting Administrator both indicated that they believed a written notice had been or would be sent, but neither could locate a copy. The Social Services Designee stated that the Administrator was responsible for written discharge notices, and the LPN was unclear about the process. Ultimately, the facility could not verify that the required written discharge notice was given to the resident or their guardian as required by policy.
Failure to Permit Resident Re-Admission After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return following a hospitalization that exceeded the bed-hold policy, despite the facility's own policy stating that a resident should be allowed to return to an available bed in their previous location or another part of the facility if necessary. The resident was discharged to a hospital after calling EMS and was ready for discharge from the hospital, but the facility refused to re-admit the resident. Multiple attempts were made by the hospital and the resident's guardian to facilitate the resident's return, but the facility's administration and clinical team consistently denied re-admission, stating they could no longer meet the resident's needs. The Director of Nursing, Administrator, and other staff confirmed their decision not to allow the resident back, even acknowledging awareness of the regulatory requirement to permit re-admission. The resident remained in the hospital for an extended period as no other facilities accepted the referral, and the facility declined multiple referrals from the hospital. Interviews with staff revealed that the decision to deny re-admission was made by the clinical team and administration, and that the facility was aware this action was contrary to regulation. The Acting Administrator later stated that, due to the length of the resident's absence, the facility believed the resident was no longer their responsibility, despite ongoing attempts to refer the resident back within the 30-day period.
Deficient Call Light System Leads to Delayed Responses
Penalty
Summary
The facility failed to maintain an effective call light system, resulting in a significant delay in responding to a resident's call light. The call light system was not functioning properly, as evidenced by multiple instances where call lights went unanswered for extended periods, ranging from 20 minutes to over 700 minutes. The facility's policy required timely responses to call lights, but the system's failure led to a resident's call light being unanswered for approximately 20 minutes. This deficiency was observed during a survey, where it was noted that the call light system only alerted at the nurse's station, and the indicator lights outside the rooms were not working. A resident, who was cognitively intact and had a history of ventricular tachycardia, chronic obstructive pulmonary disease, and repeated falls, experienced this deficiency firsthand. The resident's call light was activated, but neither the Activities Director nor LPN A were aware of it due to the malfunctioning system. The resident expressed feelings of being ignored and unimportant to the staff. The call light system's failure was further compounded by the fact that the CAT phones, which were supposed to notify staff of activated call lights, were not in use, and the Maintenance Director was unaware of the system's status. Interviews with staff, including the Maintenance Director, DON, and Regional Director, revealed a lack of awareness and communication regarding the call light system's operational status. The Maintenance Director was not responsible for the CAT phones' maintenance, and the DON was unaware of the extent of the call light delays. The Regional Director expected call lights to be answered according to policy, but the system's deficiencies prevented this. The facility's failure to ensure a functioning call light system led to significant delays in responding to residents' needs, as evidenced by the survey findings.
Resident's Dignity Compromised by CNA's Actions
Penalty
Summary
The facility failed to maintain the dignity of a resident when a Certified Nursing Aide (CNA) pulled down the resident's pants, exposing their buttocks to bystanders. This incident occurred on 9/30/24 when the resident, who was cognitively intact and had a history of residual schizophrenia and repeated falls, attempted to leave the facility during an episode of aggression. The facility's dignity policy emphasizes treating residents with respect and maintaining their privacy, which was not upheld in this situation. The incident was captured on facility cameras, and it was confirmed that CNA B was responsible for pulling down the resident's pants. CNA C witnessed the event but failed to report it to supervisors. The Director of Nursing (DON) and the Regional Director were informed of the incident on 10/3/24, and an investigation was initiated. Interviews with the involved parties revealed that the resident felt uncomfortable and embarrassed by the incident, and CNA B was assigned to monitor the resident due to self-harming behaviors earlier that day. Despite CNA B's denial of intentional misconduct, the video evidence showed the resident's dignity was compromised.
Inadequate Weight Management for Residents with PEG Tubes
Penalty
Summary
The facility failed to ensure appropriate weight management for two residents with PEG tubes, leading to discrepancies in their weight records. Resident #8 experienced a significant weight loss of 21 pounds over 34 days, which was not addressed with a re-weighing or a change in care plan. The resident's care plan did not reflect the weight loss, and there was no order for more frequent weighing despite the facility's policy requiring re-weighing for significant weight changes. Interviews with staff revealed a lack of awareness regarding the resident's weight loss and the absence of a protocol for addressing such changes. Resident #10 also faced issues with weight management, as the resident was not weighed for two months, contrary to the facility's policy of monthly weighing. The resident's weight was only recorded after a significant gap, and there was no care plan focus or intervention related to weight management. Interviews indicated that staff were unaware of the resident's weight status, and the facility's RD had to remind staff multiple times about the need for weighing the resident. The facility's scale calibration issues further contributed to the inconsistency in weight records. Interviews with various staff members, including CNAs, LPNs, RNs, and the ADON, highlighted a lack of communication and responsibility regarding weight monitoring. The ADON acknowledged the weight loss in Resident #8 and the trial diet for Resident #10, which could have contributed to weight changes. The facility's RD and physician expressed concerns about the inconsistency in weight records and the need for re-weighing residents with significant weight changes. Despite these issues, there was no indication of corrective actions or changes in treatment plans for the residents involved.
Deficiency in Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of tube feeding for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident, who had diagnoses including paraplegia, unspecified dementia, severe protein-calorie malnutrition, and dysphagia, was receiving Jevity 1.5 tube feeding at 55 ml per hour and required a flush of 150 ml of water every six hours. However, the facility did not obtain physician's orders to ensure the intake of tube feeding and fluids was completed, and there was no documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for February and March 2024 regarding the resident's tube feeding. Observations revealed that the tube feeding bag was not changed every 24 hours as required, with the same bottle observed on consecutive days. Additionally, the flush bag was not labeled, contrary to the facility's policy expectations. Interviews with nursing staff indicated a lack of clarity and consistency in documenting and managing the resident's tube feeding. The Licensed Practical Nurse (LPN) was unaware of the specific orders and did not expect the tube feeding administration to appear on the TAR, while the Registered Nurse (RN) acknowledged that the administration should be documented on the MAR/TAR and that the feeding bottle needed to be changed daily. The Assistant Director of Nursing (ADON) confirmed that tube feeding bottles should be hung for a maximum of 24 hours and expected staff to date and label both the tube feeding bottle and flush bag. The ADON also noted that there should be an order for the resident to receive tube feeding and a place on the TAR for documentation, but was unsure why this was not the case. The ADON speculated that a recent diet change might have caused the tube feeding order to drop from the resident's original Physician Order Sheet (POS), leading to the lack of documentation and scheduling on the TAR.
Failure to Ensure Accessible Call Light System for Bedbound Resident
Penalty
Summary
The facility failed to ensure that the call light system was operable and within reach for a resident who was bedbound and required total assistance from staff. The resident, who had multiple medical conditions including quadriplegia, stroke, and morbid obesity, was observed without a call light within reach. The resident reported that the call light was often on the floor and not accessible, and instead relied on a virtual assistant to call the facility for help, which was not always effective. During observations and interviews, it was noted that the resident's call light was unplugged and not available for use. Staff members, including a Certified Medication Technician and a Certified Nursing Assistant, acknowledged the absence of the call light and the resident's reliance on the virtual assistant. The facility's call light system required staff to check a monitor at the nursing station to see if a call light was activated, as there were no longer lights or sounds to alert staff directly at the resident's door. Interviews with the facility's staff, including a Registered Nurse, the Administrator, and the Assistant Director of Nursing, revealed that the resident's call light should have been plugged in and accessible. The facility was in the process of implementing a new call light system, but it was not fully operational at the time of the incident. Staff were expected to check on residents frequently and ensure call lights were available, but this was not consistently done for the resident in question.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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