River City Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson City, Missouri.
- Location
- 3038 West Truman Blvd, Jefferson City, Missouri 65109
- CMS Provider Number
- 265482
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at River City Living Community during CMS and state inspections, most recent first.
Staff failed to implement the facility’s grievance protocol when a cognitively intact resident reported a missing tablet. Facility policy required completion of a Grievance Complaint Report for lost resident items, documentation on a grievance log, and provision of a written copy and timely resolution to the resident. The grievance log showed only that the tablet was reported missing and staff were searching for it, with no completed grievance form or written response provided to the resident or guardian. The resident reported the tablet had been missing for about a month without resolution. The SSD stated he/she did not consider a missing item to be a grievance, did not complete a grievance form, and confirmed the tablet was neither found nor replaced, while the administrator acknowledged the resident should have received a resolution but did not.
Staff did not follow the facility’s investigation policy after a cognitively intact resident reported a missing tablet. The concern was recorded in the grievance log and staff searched for the item, but no thorough investigation was documented, and required interviews and reporting steps were not completed. The resident reported not receiving a response to the grievance, and the administrator acknowledged knowing about the missing tablet, speaking only with staff, and not conducting a full investigation as required by the misappropriation of property policy.
Staff failed to report an allegation of misappropriation of property to the state agency within the required timeframe. A cognitively intact resident reported a missing tablet, which was documented in the grievance log, and staff began searching for it. The facility’s abuse reporting policy addressed timelines for reporting abuse but did not specify requirements for reporting misappropriation of property. The administrator stated that staff were told to report missing items internally and acknowledged not knowing that such allegations had to be reported to the state, noting that missing items were usually found.
Facility staff did not obtain a physician's discharge order or provide a comprehensive discharge summary for a resident discharged to the community. The medical record lacked required documentation, including a summary of the resident's stay, treatment, and post-discharge care instructions, as well as a signed copy of the discharge summary. Staff interviews indicated a lack of awareness regarding follow-up resources and incomplete documentation of the discharge process.
A resident with diabetes developed a severe finger infection requiring hospitalization after a nursing assistant, unaware of the resident's diagnosis and facility policy, used an electric nail file to apply acrylic nails. The resident's care plan and facility policy specified that only licensed nurses or podiatrists should perform nail care for diabetic residents, but this was not followed, leading to a MRSA infection and surgical intervention.
Staff did not document the administration of prescribed medications for three residents, including those with severe cognitive impairment, diabetes, and chronic pain. Medications such as insulin, anti-seizure drugs, tube feedings, and pain management were not recorded as given according to physician orders, and one resident reported only receiving insulin upon request. These lapses were identified through interviews and review of medical records.
Staff failed to document the administration of medications and tube feedings for three residents, including those with severe cognitive impairment, diabetes, and ALS. Medications such as anti-seizure drugs, insulin, and nutritional feedings were not recorded as given on multiple occasions, particularly on weekends. Both the DON and administrator were aware of complaints about a weekend nurse not administering or documenting medications, but no clear action had been taken.
Staff did not notify the physician after a resident reported being touched inappropriately by another resident. Although the administrator, DHSS, corporate, and police were informed, there was no documentation of physician notification, despite facility policy requiring it when a resident's condition changes.
Facility staff did not ensure an RN was present for at least eight consecutive hours per day as required, with multiple days lacking adequate RN coverage. Time-keeping records and staff interviews confirmed the absence of an RN on several dates, and there was no policy in place for RN coverage. The DON and administrator acknowledged the deficiency and lack of a back-up plan when scheduled RNs did not report to work.
Staff did not document or complete required neurological checks for three residents with cognitive impairment after unwitnessed falls, despite facility policy and expectations from the DON, LPN, and administrator that such assessments be performed and recorded for up to 72 hours post-fall.
Facility staff did not prevent accident hazards by allowing three residents with mild cognitive impairment, all identified as smokers, to keep disposable lighters in their rooms and on their person. One resident also had oxygen therapy equipment in their room. Staff interviews confirmed awareness of the policy permitting this practice, but also acknowledged the associated safety risks.
Facility staff failed to serve food according to nutritionally calculated menus, serving smaller portions than directed. Observations showed residents on regular and pureed diets received less food than specified, with pureed bread omitted. Interviews revealed a lack of appropriate measuring tools and knowledge among staff, with the dietary manager and administrator unaware of the issue.
Facility staff failed to store food properly, leading to potential contamination and outdated use. Observations revealed undated and open food items in the refrigerator, freezer, and dry goods storage, contrary to the facility's Safe Food Handling policy. Interviews with staff indicated that the Dietary Manager and cooks were responsible for labeling and dating food, but this was not consistently done, potentially affecting all residents.
The facility failed to maintain an effective infection prevention and control program, with improper storage and handling of oxygen and nebulizer equipment for several residents. Observations showed equipment left uncovered, undated, and improperly stored, with some found on the floor. Additionally, hand hygiene practices during wound care were inadequate, as a nurse failed to perform hand hygiene and change gloves between tasks, increasing infection risk. Interviews revealed a lack of training and awareness among staff regarding infection control protocols.
The facility failed to provide and document education on the COVID-19 vaccine for staff. Policies lacked direction for staff vaccination, and interviews revealed gaps in responsibility and awareness. The business office manager, responsible for new hire paperwork, had quit, and the Infection Preventionist was unaware of staff education efforts.
The facility failed to obtain physician-ordered blood work for four residents, including tests like Hemoglobin A1C, CBC, CMP, and Depakote levels. Interviews revealed a lack of clarity in the process, with the RN unsure of who uploads results and the DON unaware of the missed tests, citing a disconnect between agency nurses and facility processes.
The facility failed to provide an ongoing activity program during weekends and evenings, affecting two residents. One resident with mild cognitive impairment did not have their activity preferences assessed, while another comatose resident's care plan preferences were not consistently followed. Observations showed limited activities and a lack of staff engagement, partly due to reliance on agency staff.
The facility failed to ensure nursing staff had the necessary skills and competencies to meet residents' care needs, lacking regular in-services and documentation of skills. Nurse aides did not receive the required 12 hours of annual training. Staff interviews revealed inadequate training on essential care areas, with reliance on previous experience. The DON acknowledged inconsistency in training, especially with agency staff, and the administrator was unaware of past training practices.
The facility failed to implement an effective antibiotic stewardship program, as staff did not track residents on antibiotics for infections. The Infection Preventionist (IP) and Director of Nursing (DON) were unclear about their responsibilities, leading to incomplete tracking. The administrator was unaware of the program's lack of implementation.
The facility failed to document the administration or refusal of pneumococcal vaccines for three residents, despite having an immunization policy. The records lacked necessary documentation, and the CDC's vaccination guidelines were not followed. Interviews revealed a lack of clarity and consistency in the immunization process, with staff unsure of the procedures and tracking systems for ensuring residents were up to date.
Facility staff failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical and nursing needs. One resident's care plan lacked directions for oxygen use and medication self-administration, while another's did not include shower preferences. A third resident experienced multiple falls without updated fall prevention interventions. The MDS Coordinator and DON acknowledged the oversight, citing workload as a contributing factor.
The facility failed to ensure the activities program was directed by a qualified professional. The Activity Director, in position since early 2024, was not certified and unaware of the requirement. The administrator also confirmed the lack of certification, only realizing it when asked for documentation.
A resident with dementia was sexually assaulted by a CNA, witnessed by another CNA who failed to report the incident immediately. The perpetrator continued working for 18 shifts post-assault. The facility's policy to protect residents from abuse was not enforced, leading to an Immediate Jeopardy situation.
A resident with dementia was allegedly sexually abused by a CNA, but the incident was not reported to the administrator until nearly a month later. The alleged perpetrator continued working additional shifts during this time. The facility's policy requires immediate reporting of such incidents, but the administrator failed to notify the DHSS within the required timeframe due to misinformation. The witnessing CNA delayed reporting, seeking proof, and was unaware of reporting protocols.
The facility failed to ensure that two CNAs received mandatory abuse and neglect training upon hire, as required by their policy. Personnel records lacked documentation of training for CNAs hired in 2020 and 2023. Interviews with facility staff, including the administrator, DON, and staffing coordinator, revealed a lack of oversight and documentation regarding the training of newly hired and agency staff.
Facility staff failed to thoroughly investigate an alleged sexual assault by a CNA on a resident with dementia. The investigation lacked interviews with the resident, other residents, and the charge nurse on duty, and did not include observations of behaviors. The former administrator delayed the investigation due to misinformation about prior reporting. The new administrator and DON acknowledged the investigation's incompleteness.
Failure to Implement Grievance Process for Resident’s Missing Tablet
Penalty
Summary
Facility staff failed to follow the facility’s grievance protocol when a cognitively intact resident reported a missing tablet. The facility’s undated Grievance Protocol policy stated that the purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to ensure proper follow-up through appropriate disciplines, with the Social Service Director (SSD) responsible for the program and the administrator ultimately responsible for its implementation. The policy specified that a Grievance Complaint Report should be used for situations involving lost or unlocatable resident articles, including ongoing concerns about lost items and laundry issues, and that the SSD would obtain the original report and forward a copy to the appropriate discipline. Review of the grievance log showed an entry indicating the resident had reported a missing tablet and that staff were searching for the item, but there was no documentation that a grievance form had been completed or that a copy had been provided to the resident or guardian. During interviews, the resident stated the tablet had been missing for about a month, that he/she had reported it to an unknown staff member, and that he/she had not been given a resolution. The SSD reported that staff were directed to report grievances to him/her or to direct residents to do so, but acknowledged not considering a missing item to be a grievance and therefore did not complete a grievance form or provide a copy to the resident. The SSD confirmed the tablet was not found or replaced and that the resident had not been provided with a resolution, and also stated being newer to the position and not recalling training on the grievance process. The administrator stated the SSD was responsible for completing a grievance form, providing it to the resident, and giving a resolution within twenty-four hours, and acknowledged that the resident’s tablet had not been replaced and that the resident should have had a resolution but it “slipped through the cracks.”
Failure to Investigate Allegation of Misappropriated Resident Property
Penalty
Summary
Facility staff failed to follow their 2017 Investigation policy requiring that every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriated resident property be thoroughly investigated and reported to the administrator and State Survey Agency within five days. The policy specified that residents, employees, family members, visitors, and others may be interviewed about their knowledge of events, and emphasized that all health care workers are mandatory reporters of abuse. Despite this, when a cognitively intact resident reported a missing tablet, staff only documented the concern in the grievance log and noted they were still searching for the item, without initiating or documenting a formal investigation as required by policy. The resident’s quarterly MDS showed the resident was cognitively intact and had been admitted earlier in the year. The grievance log entry indicated the resident reported the tablet missing, but the medical record for the relevant month contained no documentation of an investigation into the missing property. In an interview, the resident stated the tablet had been missing for about a month, that it had been reported to an unknown staff member, and that there had been no response to the grievance. In a separate interview, the administrator acknowledged awareness of the missing tablet and stated that staff searched for the item and that he/she spoke with staff, but admitted not conducting a full investigation, not following the misappropriation of property policy, and not interviewing other residents, believing instead that the item would likely turn up as missing items typically do.
Failure to Report Alleged Misappropriation of Resident Property to State Agency
Penalty
Summary
Facility staff failed to timely report an allegation of misappropriation of property to the state agency (DHSS) within the required 24-hour timeframe. The facility’s Abuse and Neglect Reporting Instructions policy directed staff to immediately report events of abuse, no later than one hour after the event, so the Administrator or designee could report abuse to the DHSS/Abuse Hotline within two hours, but the policy did not address reporting misappropriation of property within 24 hours. The facility census was 51.1. Record review showed a cognitively intact resident, admitted on a specified date, had a quarterly MDS completed on a specified date. The grievance log documented that on 01/16/26 the resident reported a missing tablet and staff noted they were searching for it. In an interview on 03/27/26, the resident stated the tablet was missing and that they had reported this to an unknown staff member. In a subsequent interview on 03/31/26, the Administrator stated staff were instructed to report missing items to the Social Service Director or to the Administrator, and acknowledged not knowing that missing items were required to be reported to DHSS, explaining that staff typically locate missing items and therefore reporting to DHSS had not been considered.
Failure to Obtain Discharge Order and Provide Comprehensive Discharge Summary
Penalty
Summary
Facility staff failed to obtain a physician's discharge order and did not provide a comprehensive discharge summary for a resident who was discharged to the community. The resident's medical record lacked documentation of a discharge order from the attending physician, and there was no evidence that a discharge summary, including a summary of the resident's stay, diagnosis, course of illness, treatment, therapy, pertinent lab and radiology results, pending lab results, special instructions for ongoing care, post-discharge plan of care, advance directive information, and medication reconciliation, was provided to the resident or their representative. Additionally, there was no signed copy of the discharge summary or post-discharge plan by the resident or their representative in the medical record. Interviews with staff revealed that the discharge process was initiated on the day of discharge, but staff were unaware of any follow-up resources being set up, such as home health services. The administrator confirmed that the facility's expectation was for the Social Services Director to arrange necessary resources and communicate them to the resident or representative, with documentation in the medical record. However, the administrator acknowledged that there was not a single form containing all required discharge information and confirmed the absence of a physician's discharge order in the resident's electronic medical record.
Injury and Infection Following Improper Nail Care for Diabetic Resident
Penalty
Summary
Facility staff failed to prevent an injury to a resident when a nursing assistant (NA) used an electric nail file to apply acrylic nails, resulting in a cut to the resident's finger. The resident had a diagnosis of diabetes and was assessed as cognitively intact, with a care plan indicating a risk for unstable blood sugars and a need for assistance with activities of daily living. According to facility policy, nursing assistants are not permitted to perform nail care on residents with diabetes or vascular disease; such care must be provided by a licensed nurse or podiatrist. Despite this, the NA performed nail care using an electric nail file on the diabetic resident, unaware of the resident's diagnosis and the associated restrictions. Following the nail care, the resident developed pain, redness, tenderness, and swelling in the right hand and arm, with symptoms rapidly progressing. Medical records documented that the resident was sent to the emergency department for probable intravenous therapy. The resident was subsequently admitted to the hospital for septic arthritis of the right index finger and underwent surgical intervention to remove infected tissue. Cultures revealed a Methicillin-resistant Staphylococcus aureus (MRSA) infection. The resident continued on antibiotics after returning from the hospital. Interviews with facility staff revealed that the NA was not aware of the prohibition against providing nail care to diabetic residents and did not realize the resident was diabetic. The NA admitted to using an electric nail file but denied causing injury or observing any immediate signs of harm. The administrator acknowledged that the NA was not supposed to perform acrylic nails or clip nails due to lack of certification. Both the facility and hospital physicians indicated that the use of the electric nail file could have contributed to the resident's infection and subsequent hospitalization.
Failure to Document Medication Administration as Ordered
Penalty
Summary
Facility staff failed to document the administration of medications as directed by physicians for three sampled residents. According to the facility's medication administration guidelines, staff are required to promptly record medication administration, including the date, time, dosage, and signature, immediately after giving the medication. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke and epilepsy, staff did not document the administration of skin prep, tube feeding formula, several anti-seizure and psychiatric medications, or the required feeding tube flushes on multiple occasions as ordered by the physician. Another resident, assessed as cognitively intact with diabetes, had undocumented administration of prescribed insulin on two separate occasions. This resident reported that insulin was only given upon request and that staff sometimes claimed it was documented even when it was not received. A third resident, also cognitively intact and diagnosed with diabetes, chronic pain, and pneumonia, had no documentation of receiving prescribed pain medication, bronchodilator, and diabetes medication on a specified date. These failures were identified through interviews and record reviews, indicating noncompliance with established medication administration and documentation protocols.
Failure to Document Medication and Feeding Administration
Penalty
Summary
Facility staff failed to document the administration of medications for three residents, as required by the facility's medication administration guidelines. The guidelines specify that medications must be given as prescribed and promptly recorded in the medical record by the person administering them. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke, seizure disorder, depression, cerebral palsy, and anxiety, staff did not document the administration of several medications, including anti-seizure drugs, antidepressants, and vitamin supplements, across multiple dates in March, April, and May. Another resident, cognitively intact and diagnosed with diabetes, had undocumented administration of insulin on several occasions, particularly on weekends, and reported not receiving insulin doses unless requested. A third resident, also cognitively intact with ALS and a feeding tube, had undocumented administration of tube feedings on several dates, with the resident reporting missed feedings on weekends. Interviews with the DON and the administrator confirmed awareness of complaints regarding a weekend nurse not administering or documenting medications, with the DON stating that issues had been reported to administration but was unsure if any action had been taken. The administrator acknowledged concerns with the weekend nurse and emphasized the expectation that staff follow physician orders and document medication administration, stating that if it is not documented, it is considered not done.
Failure to Notify Physician After Allegation of Inappropriate Contact
Penalty
Summary
Facility staff failed to notify the physician in a timely manner after an allegation of inappropriate touching was made by one resident against another. According to the facility's policy, staff are required to observe, record, and report any change in a resident's condition to the attending physician. In this incident, staff documented the allegation, notified the administrator, the Department of Health and Senior Services, corporate, and the police department, but did not document that the physician was notified. The investigation records and nurse's notes for both residents involved did not show evidence of physician notification. The residents involved included one who was cognitively intact with a diagnosis of anxiety disorder, and another who was moderately cognitively impaired with a diagnosis of bipolar disorder. Following the accusation, the resident accused was placed on fifteen-minute checks, and the administrator conducted an investigation. During an interview, the administrator acknowledged that physician notification should have occurred but was missed during the process.
Failure to Provide Required RN Coverage
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week, as required. Review of the facility's policies revealed there was no policy in place for RN coverage. Examination of time-keeping records showed that on multiple dates in December 2024, January 2025, and February 2025, the facility did not have an RN present in the building for the required eight consecutive hours. Specifically, there were several days where no RN was present for the mandated time, and on some days, no RN was present at all. Interviews with the Director of Nursing (DON) and the administrator confirmed awareness of the requirement for RN coverage. The DON, who had only recently started at the facility, was not aware of who was previously responsible for ensuring RN coverage. The administrator acknowledged ultimate responsibility for ensuring eight hours of RN coverage daily and admitted there were days without adequate RN presence, including instances where the scheduled RN did not report to work and no back-up plan was in place.
Failure to Document and Complete Neurological Checks After Unwitnessed Falls
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of practice by not documenting and completing neurological checks for three residents who experienced unwitnessed falls. According to the facility's policies, staff are required to assess and document neurological status after such events, with the expectation that neurological checks are performed for up to 72 hours following an unwitnessed fall or a fall with potential head injury. However, record reviews revealed that for three residents with cognitive impairments and a history of falls, there was no documentation in the electronic medical record (EMR) or on paper forms indicating that neurological checks were completed after their respective unwitnessed falls. Interviews with the DON, LPN, and administrator confirmed that the expectation was for staff to complete and document neurological checks after unwitnessed falls, and that these checks were to be recorded on paper and uploaded to the EMR. Despite these directives, the required documentation was missing for the identified residents, and the DON acknowledged that neurological checks should have been completed and documented for each unwitnessed fall. The facility's failure to follow its own policy and professional standards resulted in a deficiency related to the lack of post-fall neurological assessments and documentation.
Failure to Secure Lighters and Prevent Accident Hazards for Smoking Residents
Penalty
Summary
Facility staff failed to ensure the resident environment was free from accident hazards by allowing three residents, all assessed with mild cognitive impairment and identified as smokers, to keep disposable lighters in their rooms and on their person. Facility policy permitted residents with independent smoking privileges to retain cigarettes and disposable safety lighters, and staff documented these residents as safe smokers in their care plans and smoking assessments. Observations confirmed that each resident kept cigarettes and lighters in their rooms and on their person, and used them during smoking activities outside the facility. One resident had an order for oxygen therapy and an oxygen concentrator present in their room, while also keeping a lighter in their possession. Interviews with staff, including the MDS Coordinator, CNA, and administrator, acknowledged awareness of the policy but also recognized the safety concerns associated with residents keeping lighters in their rooms, particularly the risk of smoking in rooms and potential fire hazards, especially in the presence of oxygen equipment.
Failure to Serve Correct Food Portions
Penalty
Summary
The facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents, as observed during a survey. The facility's policy required measured utensils to serve portions as described on the menu. However, during an observation, it was noted that residents on regular diets were served less than the directed portions of stroganoff, noodles, and vegetables. Similarly, residents on pureed diets received smaller portions of stroganoff and noodles than specified, and pureed bread was not served at all. Interviews revealed that the cook responsible for setting serving utensils was unsure of the correct portion sizes due to a lack of appropriate measuring tools and knowledge. The dietary manager acknowledged that the cooks should serve food according to the menus but was unaware of the incorrect serving sizes. The administrator also stated that the dietary manager was responsible for ensuring correct portions were served but was not aware of the issue. The facility census was 39 with a capacity of 87.
Food Storage Deficiency in LTC Facility
Penalty
Summary
Facility staff failed to store food in a manner that prevents potential contamination and outdated use, as observed during a survey. The facility's Safe Food Handling policy requires all food, including bulk items, to be tightly sealed with an identifying label and date. However, during an observation, several food items in the reach-in refrigerator were found to be undated and open to the air, including a plastic container of pineapple, hot dogs, lettuce, tuna salad, and a zipper bag of meat. Additionally, a cardboard flat of eggs contained five broken eggs, and a one-gallon container of soy sauce was open to the air. Similar issues were observed in the reach-in freezer and dry goods storage room, where bags of beef patties, fish, pasta elbows, cookie crumbs, tortilla chips, and gravy mix were found open and undated. Interviews with facility staff, including the Dietary Manager (DM) and the administrator, revealed that the cooks and the DM were responsible for ensuring all food items were labeled, dated, and not open to the air. The DM stated that open canned items were good for seven days, and cooked items were good for three days, and no food items should be open to the air. The administrator confirmed that the DM was responsible for ensuring all food items were labeled and dated, and that prepared food items were good for three days. This failure to adhere to the facility's food storage policy has the potential to affect all residents, given the facility's census of 39 with a capacity of 87.
Infection Control Deficiencies in Equipment Handling and Hand Hygiene
Penalty
Summary
The facility staff failed to maintain an effective infection prevention and control program, as evidenced by improper storage and handling of oxygen and nebulizer equipment for several residents. Observations revealed that oxygen tubing and nebulizer masks were left uncovered, undated, and improperly stored, with some equipment found on the floor. This was noted for multiple residents, including those with cognitive impairments and respiratory conditions, indicating a lack of adherence to proper infection control protocols. Additionally, the facility's policies on oxygen administration and suctioning were found to be lacking in specific guidance on equipment storage and cleaning procedures. For instance, the suction machine used for a resident requiring tracheostomy care was observed with yellow contents inside, indicating it had not been cleansed after use. Interviews with staff, including registered nurses and certified medication technicians, revealed a lack of training and awareness regarding the facility's protocols for equipment storage and maintenance. The facility also demonstrated deficiencies in hand hygiene practices during wound care for residents with pressure injuries. Observations showed that a registered nurse failed to perform hand hygiene and change gloves between dirty and clean tasks, increasing the risk of infection spread. Interviews with the infection preventionist and director of nursing confirmed that proper hand hygiene was not consistently practiced, highlighting a significant gap in the facility's infection control measures.
Failure to Educate and Document COVID-19 Vaccine Information for Staff
Penalty
Summary
The facility staff failed to provide and document education regarding the COVID-19 vaccine's benefits, risks, and potential side effects for facility staff. The facility's Immunization policy dated February 26, 2022, and the COVID-19 for LTC policy dated May 15, 2023, did not include directions for the COVID-19 vaccine for staff. Interviews revealed that the business office manager, who was responsible for new hire paperwork including COVID-19 status review, had quit. The Infection Preventionist, new to the role since August, was unaware of any education being provided to staff and only tracked resident information. The administrator confirmed that the facility did not document education or offer guidance on obtaining the vaccine for staff.
Failure to Obtain Physician-Ordered Blood Work
Penalty
Summary
The report identifies a deficiency in the nursing facility's adherence to professional standards of care, specifically in obtaining physician-ordered blood work for four out of six sampled residents. The facility failed to provide a policy for obtaining blood work, which contributed to the oversight. Resident #1, diagnosed with diabetes, did not have a Hemoglobin A1C test conducted as ordered in August 2024. Resident #2, with heart disease and diabetes, lacked documentation for a complete blood count (CBC), complete metabolic profile (CMP), Depakote level, and Hemoglobin A1C, all of which were ordered every three months. Resident #4, diagnosed with hypertension, did not have a CBC or CMP conducted in September 2024 as ordered. Similarly, Resident #5, with hypertension, heart failure, and lung disease, did not have a CBC, CMP, or Depakote level test conducted in September 2024. Interviews with facility staff revealed a lack of clarity and responsibility in the process of obtaining and documenting blood work. RN D indicated uncertainty about who was responsible for uploading lab results into the electronic health record and suggested that the Director of Nursing (DON) should oversee the lab process. The DON, new to the role, was unaware of the missed blood work and acknowledged a disconnect between agency nurses and facility processes. The administrator, who recently hired a medical record staff member to manage document uploads, was also unaware of the issues with blood work completion and expected nursing staff to follow up on all physician orders.
Lack of Weekend and Evening Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program during weekends and evenings, which did not meet the needs of two dependent residents. The activity calendar for September and October 2024 showed limited activities, primarily consisting of bible study and occasional puzzles or coloring. Interviews with staff and residents revealed that organized activities were lacking, particularly on weekends, and staff often did not have time to engage residents in activities. Resident #6, who had mild cognitive impairment, did not have their activity preferences assessed or included in their care plan. The resident expressed a desire for more organized activities on weekends. Resident #1, assessed as comatose with a diagnosis of persistent vegetative state, had specific preferences documented in their care plan, such as enjoying looking out the window, listening to gospel music, and being taken out of their room. However, observations showed the resident was often left in a dark room with curtains closed, contrary to their care plan. Interviews with staff indicated a lack of consistency in following the resident's preferences, partly due to the use of agency staff who may not be aware of the activity requirements. The Activity Director acknowledged the challenges in providing consistent activities due to staffing issues.
Inadequate Staff Training and Competency Assessment
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate skills and competencies to meet the care needs of residents. This was evidenced by the lack of regular in-services, re-evaluation, and documentation of skills and competencies for each employee. Additionally, nurse aides did not receive the required 12 hours of in-service education annually. The facility's Orientation and Training policy did not specify the frequency of education, documentation methods, or a comprehensive list of necessary in-services, including critical areas such as abuse and neglect, dementia care, and specialized resident needs. The facility's assessment highlighted the need for initial training upon hire, ongoing professional development, and periodic competency assessments for staff. However, the review of the facility's in-service annual training revealed incomplete documentation, with no records of skills and competencies or the required 12-hour nurse aide training. Interviews with staff, including a Certified Medication Technician, RNs, and CNAs, indicated that they did not receive adequate training on essential care areas such as oxygen use, COVID-19 protocols, dementia care, and other specialized care techniques. Staff often relied on their previous experience or knowledge rather than facility-provided training. The Director of Nursing acknowledged the inconsistency in training, particularly with agency staff, and admitted that the facility assumed agency staff were competent without conducting their own assessments. The administrator, who had only been at the facility for a few months, was unaware of previous training practices and confirmed that CNAs are required to have 12 hours of training annually. The facility had recently received a list of yearly trainings from the corporate office, but there was no evidence of a structured training program in place prior to this.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an effective antibiotic stewardship program, as evidenced by the lack of tracking of residents on antibiotics for various infections. The facility's Antibiotic Stewardship Program outlined responsibilities for the Infection Preventionist (IP) and designee, including auditing clinical assessment documentation and tracking antibiotic-resistant infections. However, the review of the Antibiotic Tracking binder showed it was incomplete, with the most recent line blank. Interviews revealed that the IP had only recently assumed the role and was not fully aware of the tracking responsibilities, while the Director of Nursing (DON) acknowledged not tracking antibiotics despite having received a form to do so. The administrator was under the impression that the antibiotic stewardship program was reviewed during weekly risk meetings but was unaware that it had not been implemented. The DON admitted to planning to start tracking antibiotics but had not yet begun the process due to other pressing issues. This lack of action and communication among staff members led to the deficiency in the antibiotic stewardship program, as there was no current and ongoing log of residents with active infections being treated with antibiotics.
Failure to Document Pneumococcal Vaccinations
Penalty
Summary
The facility staff failed to document the administration or refusal of the pneumococcal vaccine for three of five sampled residents, despite having an immunization policy in place. The policy required a physician order, consent from the resident or legal representative, and documentation of the vaccine administration in the resident's medical record. However, the records for these residents did not contain the necessary documentation, indicating a lapse in following the established procedures. The CDC's guidelines for pneumococcal vaccination were also not adhered to, as the records lacked evidence of the required vaccinations being administered or refused. Interviews with facility staff revealed a lack of clarity and consistency in the immunization process. The Director of Nursing acknowledged that immunizations were a work in progress and expressed uncertainty about the process before their tenure. The Infection Preventionist, responsible for vaccine status since August, admitted to only reviewing new admissions and not having a system for tracking long-term residents due for vaccines. The administrator confirmed that the Infection Preventionist was in charge of vaccine tracking but was unsure of how the process was being managed to ensure residents were up to date.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical and nursing needs. For one resident, the care plan did not include directions for oxygen use or the ability to keep medication at the bedside, despite observations of the resident using oxygen and having medication on the nightstand. The MDS Coordinator was unaware of these needs and acknowledged that oxygen use and self-administration should be part of the care plan. Another resident's care plan lacked information on shower preferences and the level of assistance required, even though the resident was assessed as cognitively impaired and requiring supervision during showers. The resident expressed feeling unclean due to not having a bath or shower while on isolation. The MDS Coordinator admitted there was miscommunication regarding the resident's shower abilities and that the care plan had not been updated. A third resident experienced multiple falls, yet the care plan did not include new interventions or updates for fall prevention. The MDS Coordinator stated that falls are usually updated in the care plan after weekly at-risk meetings but could not explain why this had not occurred. The DON and administrator acknowledged the responsibility of updating care plans with changes in resident status, but both cited being busy with other duties as a reason for the oversight.
Unqualified Activity Director Leads to Deficiency
Penalty
Summary
The facility staff failed to ensure that the activities program was directed by a qualified professional. The facility's policy, dated March 2012, requires that the activity program be directed by a certified Activity Director who is directly responsible to the administrator. However, during an interview, the current Activity Director admitted to not being certified and was unaware of the certification requirement, despite having held the position since February 2024. Additionally, the administrator confirmed that the Activity Director was not certified and acknowledged being unaware of this until prompted to provide the certification.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to protect a resident from sexual abuse when a Certified Nurse Assistant (CNA) sexually assaulted the resident. The incident was witnessed by another CNA, who did not intervene or report the abuse immediately. This failure allowed the perpetrator to continue working at the facility for 18 additional overnight shifts after the assault was observed. The facility's policy mandates that residents be free from abuse, neglect, and harm, but this policy was not effectively enforced in this case. The resident involved had a diagnosis of dementia, which impaired their ability to consent or understand the situation. The witnessing CNA documented the incident in a written statement and recorded a video of the assault, although the video quality was poor. Despite suspecting inappropriate behavior for some time, the witnessing CNA delayed reporting the incident due to a lack of concrete evidence and concerns about making false accusations. The local law enforcement was notified, and an investigation was conducted. The perpetrator admitted to having sexual intercourse with the resident, acknowledging the resident's dementia diagnosis. The facility's failure to act promptly and protect the resident from further abuse resulted in an Immediate Jeopardy situation, which was later addressed by the facility.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident with dementia in a timely manner. The incident was witnessed by a Certified Nurse Assistant (CNA) on April 17, 2024, but was not reported to the administrator until May 13, 2024. During this period, the alleged perpetrator, another CNA, continued to work 18 additional shifts. The facility's policy requires that such allegations be reported to the administrator and the state survey agency within two hours if serious bodily injury is suspected. However, the administrator did not report the incident to the Department of Health and Senior Services (DHSS) within the required timeframe, as he/she was initially misinformed that the allegation had already been reported and investigated. The CNA who witnessed the incident did not intervene or report immediately because he/she wanted to gather proof by attempting to enhance a video recording of the event. The CNA was unaware of the timeframe for reporting abuse or neglect and had not attended recent abuse in-service training. Interviews with the current administrator and Director of Nursing revealed that staff are directed to remove residents to safety and report incidents immediately, but this protocol was not followed. The deficiency was identified as an immediate and serious jeopardy level violation, indicating a significant failure in the facility's abuse reporting procedures.
Failure to Implement Abuse and Neglect Training
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures effectively, as evidenced by the lack of training for two Certified Nurse Aides (CNA A and D) out of four sampled staff. The facility's policy required all new employees and volunteers to receive training on the abuse policy before having any resident contact. However, a review of personnel records showed that CNA A, hired on 10/03/23, and CNA D, hired on 10/23/20, did not have documentation of receiving this mandatory training. Furthermore, during an interview, CNA D was unable to recall when they last attended an abuse in-service or the timeframe for reporting abuse or neglect. The facility's administration, including the current administrator, Director of Nursing (DON), and Staffing Coordinator, acknowledged the oversight in training. The administrator and DON both stated that the staffing coordinator was responsible for conducting abuse and neglect training for all newly hired staff, including agency staff, and ensuring annual training for existing staff. However, they could not find documentation that agency staff received the required training. The staffing coordinator, who was not in the position when CNA A and D were hired, confirmed conducting an abuse and neglect in-service during orientation for agency staff but did not provide evidence of training for the CNAs in question.
Incomplete Investigation of Alleged Sexual Assault
Penalty
Summary
The facility staff failed to conduct a thorough investigation following an allegation of sexual assault by a Certified Nurse Aide (CNA) against a resident. The facility's policy mandates that reports of abuse be promptly and thoroughly investigated, including interviews with involved parties and observations of behaviors. However, the investigation into the alleged incident, which reportedly occurred between 4:30 A.M. and 5:30 A.M., lacked documentation of interviews with the resident involved or any other residents, and there were no observations of resident and staff behaviors. Additionally, the charge nurse on duty during the incident was not interviewed. The former administrator did not initiate the investigation promptly, as they were initially informed that the allegation had been previously reported and investigated. It was later revealed that the allegation had not been reported, leading to a delayed investigation. Interviews with the newly hired administrator and Director of Nursing (DON) revealed that they believed the investigation was incomplete due to the lack of resident interviews and the omission of the charge nurse's interview. The facility census at the time was 52, and the resident involved had a diagnosis of dementia.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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