Shirkey Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Missouri.
- Location
- 804 Wollard Blvd, Richmond, Missouri 64085
- CMS Provider Number
- 265708
- Inspections on file
- 20
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Shirkey Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
During a survey, it was observed that the facility did not adhere to food storage and labeling protocols. Open and undated food items were found in the kitchen, including a bag of yellow cake mix, thickener with scoops inside, loaves of bread, and a bag of frozen chicken breasts. The Dietary Manager acknowledged that scoops should not be kept in containers and that staff were expected to label and date items properly. The deficiency had the potential to impact all 86 residents consuming food from the facility's kitchen, posing possible health risks due to compromised food safety standards.
The facility failed to have the Medical Director or designee attend the last two quarterly QAPI meetings. The QAPI Nurse confirmed the absence and acknowledged the regulatory requirement for attendance.
The facility failed to update Care Plans for two residents, one with Alzheimer's disease exhibiting undocumented behaviors and another with chronic conditions requiring continuous oxygen, leading to deficiencies in care.
The facility failed to provide scheduled showers to two residents who preferred showers, leading to a diminished quality of life. Both residents, who were cognitively intact and required substantial assistance, missed multiple showers due to staffing shortages, as confirmed by documentation and staff interviews.
The facility failed to assess and monitor a resident's falls, leading to multiple incidents without proper intervention. Additionally, the facility did not provide necessary safety equipment in smoking areas and failed to conduct proper smoking assessments, increasing the risk of harm to residents.
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in the management of oxygen and C-PAP equipment. Oxygen tubing was not dated or labeled, C-PAP machines were improperly placed, and there was no evidence of regular cleaning or changing of equipment. Staff admitted to inconsistent maintenance, and the DON confirmed the lack of proper documentation and adherence to protocols.
The facility failed to ensure sufficient nurse staffing, resulting in two residents not receiving scheduled showers and a lack of meaningful activities for residents in the secured dementia unit. Observations and staff interviews confirmed that the unit was understaffed, affecting the quality of care and engagement for the residents.
The facility failed to complete AIMS assessments for residents on antipsychotic medications, including a resident with heart failure and diabetes, another with Alzheimer's disease, and a third with dementia and bipolar disorder. This oversight placed residents at risk for unrecognized side effects.
The facility failed to prepare, store, and label medications according to standard nursing practice. A CMA was observed leaving a medication cart unattended with unlabeled medications and admitted to premixing medications against facility policy. The DON confirmed that medications should not be prepared in advance or left unattended.
The facility failed to document the completion of 12 hours of required in-service training, including dementia care and abuse prevention, for five CNAs. Despite conducting annual trainings, there was no evidence that the required hours were met, and the facility did not track the actual hours completed.
The facility failed to inform a resident and/or their representative about the risks and benefits of prescribed psychotropic medications. The resident, who was cognitively intact, was not informed about the medications Seroquel and Rexulti, and the documentation in the Progress Notes was incomplete. Interviews with staff confirmed that the process for informing residents was not properly followed.
The facility failed to investigate an injury of unknown source for a resident with a history of osteoarthritis, falls, and heart failure. Despite the resident's complaints of knee pain and a reported femur fracture, no investigation was initiated by the nursing staff or the Director of Nursing Services. The resident was later sent to the hospital, where an x-ray revealed a femur fracture. Interviews revealed that the facility did not follow its policy for investigating injuries of unknown source.
The facility failed to provide a program of meaningful activities for a resident with Alzheimer's disease, who was often left without engaging activities and seen wandering or sitting on the floor. The CNA/CMA was unaware of the resident's preferences, and the Activity Director admitted to delays in developing the Activity Care Plan and acknowledged that residents were spending more time in bed.
The facility failed to ensure that a CMA had the necessary skills and competency to safely perform medication administration. CMA 3 had not been assessed for medication competency since 2023 and was only observed for insulin, eye drops, and inhalers.
Non-Compliance with Food Storage and Labeling Requirements
Penalty
Summary
The facility failed to comply with food storage and labeling requirements during the survey. Observations revealed open and undated food items in the kitchen, including an open bag of yellow cake mix, thickener with scoops inside, undated loaves of bread, and an undated bag of frozen chicken breasts. The Dietary Manager acknowledged that scoops should not be kept in containers, and staff were expected to label and date items properly. The DM also mentioned the expectation for staff to close items after use and ensure proper labeling and dating procedures were followed. The deficiency had the potential to impact all 86 residents who consumed food prepared in the facility's kitchen. The lack of proper labeling and dating of food items could compromise food safety standards and potentially lead to health risks for the residents. The facility's policy on Resident Food Storage required labeling and dating of food brought into the facility for monitoring food safety, emphasizing the importance of following these procedures to ensure the well-being of the residents.
Medical Director Absence from QAPI Meetings
Penalty
Summary
The facility failed to have the Medical Director and/or designee attend the last two quarterly QAPI (Quality Assurance and Performance Improvement) committee meetings. Review of the QAPI sign-in sheets for the meetings on 11/28/23 and 02/20/24 revealed that the Medical Director did not attend and was marked as 'unable to attend' for both meetings. During an interview on 04/05/24, the QAPI Nurse confirmed that the Medical Director did not attend the last two meetings and acknowledged awareness of the regulatory requirement for the Medical Director or their designee to attend these meetings.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure resident Care Plans were updated and revised for two residents, leading to deficiencies in care. Resident 84, diagnosed with Alzheimer's disease, exhibited behaviors such as sitting on the floor, which were not documented in her Care Plan. Despite observations and staff acknowledgment of this behavior, it was not included in the Care Plan, leaving staff without guidance on how to address it safely. The Unit Manager confirmed that the behavior was reported but not documented in the Care Plan, indicating a lapse in updating the resident's Care Plan to reflect her current status. Resident 6, with diagnoses including chronic congestive heart failure and chronic atrial fibrillation, had a continuous oxygen order that was not included in their Care Plan. Despite the resident using oxygen since their last hospital visit, the Care Plan did not address this need. The Assistant Director of Nursing, responsible for updating Care Plans, admitted to missing the oxygen requirement during the last significant change assessment. This oversight left staff without proper instructions on managing the resident's oxygen needs.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide showers to two residents who preferred showers, leading to a diminished quality of life. Resident 8, who was admitted with diagnoses including Parkinson's disease, dementia, and anxiety, had a BIMS score indicating she was cognitively intact and required substantial assistance with showering. Despite her care plan specifying she should receive showers twice weekly, there were multiple instances where she did not receive a shower, which she attributed to staffing shortages. Documentation confirmed the lack of showers on specific dates in January, February, and March 2024. Similarly, Resident 73, admitted with cerebral palsy and mental illness, also had a BIMS score indicating cognitive intactness and required substantial assistance with showering. Her care plan indicated she should receive showers twice weekly, but she reported not receiving them due to staffing issues. Documentation confirmed missed showers on specific dates in January, February, March, and April 2024. An LPN confirmed that staffing shortages were likely the reason for the missed showers, as the facility could not always assign a CNA to assist with showers when understaffed.
Failure to Assess Falls and Provide Smoking Safety Measures
Penalty
Summary
The facility failed to adequately assess and monitor a resident's falls, leading to multiple incidents without proper intervention. Resident 23, who was admitted with various diagnoses including dementia and epilepsy, experienced fourteen falls over a six-month period. Despite these frequent falls, there was no documentation of fall assessments or root cause analysis. Interviews with staff and family members revealed a lack of consistent interventions and monitoring, with the resident often found in unsafe conditions such as a raised bed without proper supervision or safety measures in place. The Director of Nursing (DON) admitted that no root cause analysis or evaluations had been conducted for the resident's falls, and the facility's records did not indicate when or what interventions were implemented to prevent further falls and injuries for Resident 23. The facility also failed to provide necessary safety equipment in designated smoking areas and did not conduct proper smoking assessments for residents. Observations revealed that the three designated smoking areas lacked fire blankets and fire extinguishers, posing a significant risk to residents who smoke. One resident, who was supposed to be supervised while smoking, was observed smoking unsupervised for several minutes before a staff member arrived. The DON admitted that smoking assessments were not conducted, and there was no documentation to show that the resident's smoking abilities had been assessed. This lack of assessment and supervision increased the risk of harm to residents who smoke. Interviews with staff and review of facility policies highlighted systemic issues in the facility's approach to resident safety and risk management. The facility's policies on unusual occurrences and smoking were not adequately followed, leading to repeated incidents and potential hazards. The DON and other staff members were often unaware of the specific interventions or assessments required to ensure resident safety, indicating a need for improved training and adherence to established protocols.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in the management of oxygen and C-PAP equipment. For one resident, the oxygen tubing was not dated or labeled, and the C-PAP machine was improperly placed on the floor. Additionally, there was no evidence that the C-PAP mask, tubing, and water chamber were cleaned or changed as per physician orders. Interviews with the resident and staff revealed inconsistencies in the maintenance and documentation of respiratory equipment, with staff admitting to changing the equipment on an 'as needed' basis rather than following a set schedule. Another resident was observed with a nasal cannula that was not properly positioned in both nares, and the oxygen concentrator filter was found to be dirty. The resident was also seen without her oxygen on multiple occasions, and staff were unsure why the oxygen was not being used. The facility's Director of Nursing (DON) and other staff members confirmed that the oxygen tubing and C-PAP equipment were not being maintained as required, and there was a lack of proper documentation to verify that the necessary cleaning and changes were being performed. The facility's policy required weekly cleaning and changing of oxygen and C-PAP equipment, but observations and interviews indicated that these tasks were not being consistently carried out. The DON acknowledged the deficiencies and stated that the night shift aides were responsible for these tasks, but the lack of documentation suggested that the procedures were not being followed. This failure to adhere to established protocols placed the residents at risk for respiratory illnesses and contamination of their respiratory equipment.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nurse staffing to meet the needs of the residents, resulting in residents not receiving showers and a lack of meaningful activities in the secured dementia unit. Specifically, two residents, R73 and R8, did not receive their scheduled showers due to staffing shortages. R8 reported not having a shower for seven days, and R73 confirmed that showers were missed because of short staffing. Both residents were cognitively intact and expressed concerns about the lack of care. Additionally, the facility's quarterly Minimum Data Set (MDS) confirmed these residents' cognitive status and their unmet needs for showers. The facility also failed to provide a program of meaningful activities for residents in the secured dementia unit. Observations revealed that residents were often lying in bed or wandering without engagement. Only one staff member was available to assist nine residents with activities of daily living (ADL), medication administration, behavior management, and activities. Interviews with staff, including a Certified Nurse Aide (CNA), Licensed Practical Nurse (LPN), and the Activities Director (AD), confirmed that the unit was understaffed and that the move to a new hall had further limited the residents' access to outdoor activities and adequate care. The facility assessment indicated that the previous staffing levels were higher, but the current staffing was insufficient to meet the residents' needs.
Failure to Complete AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments for residents who were administered antipsychotic medications, placing them at risk for unrecognized side effects. Resident 65 was admitted with diagnoses including heart failure, diabetes, and pulmonary disease. Despite being prescribed Seroquel and later Rexulti, there was no documentation of an AIMS assessment being completed. The Director of Nursing (DON) confirmed that AIMS assessments were the responsibility of Unit Managers and should be done upon admission and every six months thereafter, but could not confirm if these assessments were completed for Resident 65. Resident 84, admitted with Alzheimer's disease, was also not assessed using AIMS upon admission or when prescribed Olanzapine and Risperidone. The Unit Manager acknowledged that the AIMS assessment was not done and could not provide a reason. This oversight was confirmed during an interview, highlighting a gap in the facility's protocol for monitoring residents on antipsychotic medications. Resident 4, diagnosed with unspecified dementia, bipolar disorder, and anxiety, was observed exhibiting tongue thrusting, a potential side effect of antipsychotic medication. Despite a care plan that included AIMS assessments every three months, there was no documentation of these assessments being completed. The DON could not provide any records of AIMS evaluations or routine assessments for Resident 4's psychotropic medication use, indicating a failure to follow the care plan and monitor for side effects effectively.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to prepare, store, and label medications according to standard nursing practice, as observed during a medication pass. Certified Medication Aide (CMA3) was seen leaving a medication cart unattended with three individual plastic cups containing unlabeled medications. CMA3 admitted to premixing medications, including Lactulose, liquid protein, and Miralax, and leaving them on the cart. This practice was against the facility's policy, which mandates that medications should never be left unattended and should be locked inside the cart if the cart is left unattended. Further observations revealed that CMA3 continued this practice with another medication cart, which also had five individual plastic cups of unlabeled medications on top. CMA3 admitted to premixing these medications about an hour prior and stated that she could identify the medications without labels. The Director of Nursing (DON) confirmed that the expectation was for medications not to be prepared in advance and not to be left unattended on the carts.
Failure to Document Required In-Service Training Hours
Penalty
Summary
The facility failed to document the completion of a minimum of 12 hours of required in-service training, including dementia care and abuse prevention, for five Certified Nursing Assistants (CNAs). Despite annual trainings being conducted, there was no evidence that the required 12 hours were completed for CNAs 1, 2, 4, 6, and 7. Interviews with CNAs revealed that while they received some training on abuse and neglect, dementia care training was either minimal or non-existent. The facility's Facility Assessment indicated the need for 12 hours of annual training, but this requirement was not met or documented properly. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that they did not track the actual hours of training completed by staff. The IP mentioned that while they conducted various trainings, they did not document the number of hours. Similarly, the DON stated that although staff signed in for trainings, there was no system in place to ensure the 12-hour requirement was met. This lack of documentation and tracking led to the deficiency, putting residents at risk of not receiving adequate care from properly trained staff.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of physician-ordered psychotropic medications. Specifically, Resident 65, who was cognitively intact with a BIMS score of 14 out of 15, was not informed about the risks and benefits of Seroquel and Rexulti, which were prescribed for increased behaviors, hallucinations, paranoia, and depression. The documentation in the Progress Notes did not show that the resident or their representative was informed prior to the initiation of these medications. During interviews, it was revealed that the facility's process for informing residents or their representatives about new psychotropic medications involved a phone call, which was then documented in the Progress Notes. However, in this case, the documentation was incomplete, and the Licensed Practical Nurse and Director of Nursing confirmed that if it was not documented, it did not happen. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the medications being administered.
Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to investigate an injury of unknown source for a resident, which placed the resident at risk for potential abuse. The resident, who had a history of osteoarthritis, falls, and heart failure, reported being unable to stand due to knee pain. Subsequent progress notes indicated that the resident mentioned breaking her femur and experiencing pain, but no falls were reported by the staff. Despite the resident's complaints and the family's concerns, no investigation was initiated by the nursing staff or the Director of Nursing Services (DNS) when the injury was first reported. The resident was later sent to the hospital at the family's request, where an x-ray revealed a femur fracture. The acuity of the fracture was uncertain, but it could not be excluded as an acute fracture. Upon readmission to the facility, the resident's condition had deteriorated, and she was no longer able to walk. The resident and her family reported that the resident had been dropped by staff, which was not documented or investigated by the facility. Interviews with the resident, family member, and staff revealed that the facility did not follow its policy for investigating injuries of unknown source. The Director of Nursing (DON) was unaware of the x-ray report and the resident's statements, and no investigation was conducted. This lack of action and communication among the staff led to the failure to investigate the resident's injury, which is a violation of the facility's policy and federal and state laws regarding the treatment of residents.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to consistently provide a program of meaningful activities in accordance with a resident's preferences. The resident, diagnosed with Alzheimer's disease and severely impaired in cognition, was admitted to the facility and had a documented preference for activities such as attending church, watching specific TV shows, hiking, and enjoying chocolate and Mountain Dew. However, observations revealed that the resident was often left without engaging activities, seen sitting on the floor or wandering around, with minimal staff intervention. The CNA/CMA on duty was unaware of the resident's specific activity preferences and there was no activity logbook available to guide staff in providing appropriate activities. The Activity Director admitted to delays in developing the resident's Activity Care Plan and acknowledged that the residents were spending more time in bed. The AD also noted that the aide on the dementia unit was supposed to conduct activities with the residents, but this was not happening consistently. The recent move of residents to a new unit had also impacted the availability of outdoor activities and other engagement opportunities. The AD mentioned attempts to engage residents with activities like bingo, but overall, the facility's efforts to provide meaningful activities were insufficient, leading to a diminished quality of life for the resident.
Failure to Ensure Medication Competency of Certified Medication Aide
Penalty
Summary
The facility failed to ensure that a Certified Medication Aide (CMA) had the necessary skills and competency to safely perform medication administration. Specifically, CMA 3, who was hired on 07/11/02, had not been assessed for medication competency since 04/11/23. The Skills and Drills sheet provided by an LPN showed that CMA 3 was only observed for insulin, eye drops, and inhalers, and had not been assessed for any other medication pass requirements. During an interview, the LPN confirmed that CMA 3 had not undergone a comprehensive medication pass observation since 2023.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
