Webco Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshfield, Missouri.
- Location
- 1687 West Washington, Marshfield, Missouri 65706
- CMS Provider Number
- 265520
- Inspections on file
- 23
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Webco Manor during CMS and state inspections, most recent first.
A resident with cardiac and pulmonary conditions, initially defaulted to full code status, later completed a physician-signed DNR order that was placed in an admission folder but not communicated to nursing or entered into the EMR. The Admissions Director did not forward the DNR paperwork to the SSD or DON, and the SSD created the resident’s profile as full code, leaving the hard chart, EMR, and door sticker system all reflecting full code. When the resident was found unresponsive, staff and EMS initiated and continued CPR based on the incorrect full code information, and only afterward did the SSD discover the signed DNR form in the admission packet.
A resident with multiple sclerosis and minimal cognitive impairment reported to a CNA that a CNA staff member was rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall above the resident’s head after being told to stop, causing the resident to feel fearful and request that the CNA not return. The CNA immediately informed an RN, wrote a statement, and attempted to contact the DON and Administrator by phone and text, but neither responded during the night. The RN reassigned the resident’s care and told the accused CNA not to re-enter the room but did not interview the resident and did not treat the report as an abuse allegation, so it was not escalated to leadership until later that morning, during which time the accused CNA continued working independently with other residents.
A resident with MS and minimal cognitive impairment reported that a CNA was rough during incontinence care, turned on a bright light while the resident was sleeping, and punched the wall above the resident’s head, causing the resident to feel fearful and request that the CNA not return. A CNA promptly informed the RN, documented the incident, and attempted to contact the DON and Administrator by phone and text, but the RN did not escalate the report, believing rough care was not abuse, and leadership did not respond during the night. The allegation was not documented in the resident’s progress notes, and the Administrator did not submit the required report to the State until more than seven hours after staff first became aware of the allegation, exceeding the facility’s two-hour reporting requirement for abuse allegations.
A resident with severe cognitive impairment was subjected to alleged abuse by a CNA, who placed a hand over the resident's mouth and used inappropriate language. The incident was witnessed by another CNA, who did not report it immediately but waited until the next day to inform another staff member, resulting in a delayed report to the DON, Administrator, and state agency. This delay exceeded the required two-hour reporting timeframe for abuse allegations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with neurogenic bladder continued to have an indwelling urinary catheter in place and performed their own catheter care, but there was no current physician order specifying the catheter's use, size, or change frequency, despite staff awareness of this omission.
The facility failed to notify the families of two residents after a significant change in condition and an allegation of abuse. A resident with dementia was involved in inappropriate touching, but their family was not informed. The facility's investigation revealed a lack of communication and documentation, and staff interviews confirmed that families should have been notified.
A facility failed to report allegations of sexual abuse involving inappropriate touching between residents to management and DHSS within the required timeframe. Despite staff awareness of the reporting protocol, incidents were not documented or reported promptly, leading to a deficiency in the facility's abuse prevention and reporting procedures.
A facility failed to investigate an alleged abuse incident when a resident was seen touching another resident inappropriately. Despite facility policies requiring immediate investigation and reporting, no documentation or investigation was conducted. Staff, including the DON and Administrator, were unaware of the incident, highlighting a deficiency in handling the situation.
A resident with dementia and psychotic disturbances exhibited inappropriate touching behavior towards other residents, but the facility failed to update the care plan to reflect these incidents. Despite staff awareness and documentation of the behavior, the MDS Coordinator did not amend the care plan, indicating a deficiency in the care planning process.
A resident with chronic pain syndrome and arthritis experienced inadequate pain management due to the facility's failure to document pain levels, follow up on medication effectiveness, and communicate with the physician about increased pain and unavailable medications. The resident's condition worsened, leading to a hospital transfer where a patella fracture was diagnosed.
A resident with rheumatoid arthritis experienced a decline in mobility and increased knee pain, which was not promptly communicated to the provider. Despite staff observations of the resident's swollen, red, and warm knee, and the resident's requests for medical attention, there was a delay in notifying the physician. The resident was eventually transferred to the hospital, where a patellar fracture was diagnosed.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to inadequate supervision and failure to implement necessary interventions. Despite triggering alarms and exhibiting exit-seeking behavior, the resident was not placed on 15-minute checks or given increased supervision. The resident was later found in a nearby cornfield after a search involving law enforcement.
Failure to Communicate and Update Resident DNR Status Resulting in CPR Contrary to Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s code status preference was clearly and accurately reflected in the medical record and available to staff, resulting in CPR being initiated contrary to the resident’s documented wishes. The resident was admitted with diagnoses including atrial fibrillation, cardiac disease, stroke, and lung disease, and was initially listed as a full code in the facility’s electronic medical record and on the face sheet. The facility’s practice was to default all new admissions to full code status until staff could confirm the resident’s preferences. The resident had normal cognition on the admission MDS and later completed an Outside Hospital Do-Not-Resuscitate (OHDNR) order, which was signed and dated by both the resident and the physician. The sequence of events leading to the deficiency began when the Admissions Director completed the admission paperwork with the resident, including code status and DNR documentation, and then placed all forms in a folder on their desk before leaving for the weekend. The Admissions Director did not notify nursing staff that the resident’s code status had changed from full code to DNR, did not make copies for the nursing charts, and did not provide the DNR paperwork to the Social Services Director (SSD) or the Director of Nursing (DON). As a result, the SSD created the resident’s electronic profile as a full code and did not receive or review the signed DNR form until after the resident’s death. The DON reported not receiving any DNR paperwork prior to the resident’s cardiopulmonary arrest, and the resident’s orders were not updated in the hard chart, EMR, or on the red/green door sticker system used to indicate code status. When the resident was later found unresponsive, staff followed the information available to them, which indicated the resident was a full code. Staff immediately called the nurse, initiated CPR, and called 911. EMS arrived and continued CPR for over an hour. During this time, the DON was called to the facility and contacted the family while the code was in progress. The resident’s progress notes documented the discovery of the resident unresponsive, the initiation of CPR, EMS involvement, and subsequent notifications to the family and physician. Only after these events did the SSD, while scanning the admission packet into the EMR, discover the signed DNR order that had not been communicated or entered into the resident’s record, confirming that staff had provided CPR despite the resident’s documented DNR preference.
Failure to Immediately Investigate and Protect Resident After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately and thoroughly investigate an allegation of staff-to-resident abuse and to ensure resident protection during the investigation. The facility’s Abuse and Neglect Policy requires the Administrator, DON, or designee to begin an internal investigation immediately and report to DHSS when an allegation arises. A resident with multiple sclerosis and minimal cognitive impairment, admitted in early February, reported to a CNA that a CNA staff member had been rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall three times above the resident’s head after being told to stop. The resident stated fear of this CNA and requested that the CNA not return to the room. CNA A documented the allegation in a written statement and immediately reported it to RN C during the night shift. CNA A then attempted to contact the DON and the Administrator by phone and text, sending a picture of the written statement to both, but received no response at that time because both leaders were asleep and did not hear their phones. RN C reassigned the resident’s care to CNA A and instructed CNA B not to return to the resident’s room, but did not enter the resident’s room or interview the resident about the allegation. RN C stated that being rough with cares was not considered an allegation of abuse and therefore did not report the incident to the DON or Administrator during the night. The Administrator and DON later acknowledged that rough care and punching a wall constituted abuse and that an investigation should have been started immediately. Other nursing staff interviewed indicated that any report of rough care where a resident does not feel safe should be treated as an abuse allegation, with immediate steps to ensure safety and report to leadership. Despite this, there was a delay from the time of the initial report during the night until the Administrator became aware and began an investigation later that morning, during which time the staff member implicated in the allegation continued to work independently with residents.
Failure to Timely Report Allegation of Rough Care and Threatening Behavior
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two hours after staff became aware of the allegation. The facility’s abuse policy required that any suspicion or knowledge of abuse, neglect, or misappropriation be reported immediately to the Administrator and charge nurse, and that the Administrator, DON, or designee begin an internal investigation immediately and report to DHSS within two hours if the allegation involved serious injury, or within 24 hours if it did not. A resident with multiple sclerosis and minimal cognitive impairment, admitted on 02/02/24, reported that a CNA had been rough during incontinence care and had punched the wall above the resident’s head, causing the resident to feel fearful and not want that CNA to return. In the early morning hours, between approximately 2:00 A.M. and 2:25 A.M., a CNA entered the resident’s room to provide care and was informed by the resident that another CNA had turned on a bright light while the resident was sleeping, was rough while attempting to change the resident, and, after being told to stop, punched the wall three times above the resident’s head before leaving. The CNA immediately reported the incident to the charge RN, wrote a statement, and attempted to notify the DON and Administrator by phone and text, including sending photos of the written statement. The charge RN acknowledged being informed between 2:00 A.M. and 3:00 A.M. that the resident complained of rough care and that the CNA had punched a wall, reassigned staff so the alleged CNA would not return to the room, but did not report the allegation to the DON or Administrator, believing that “rough with cares” was not an allegation of abuse. Despite the CNA’s attempts to contact leadership during the night, the DON and Administrator did not respond at that time, later stating they had been sleeping and did not hear their phones. The Administrator did not confirm the incident with staff until later that morning and did not submit the online report to DHSS until 9:58 A.M., more than seven hours after staff first became aware of the allegation. Facility records showed no progress note documentation of the allegation in the resident’s chart. Interviews with other nursing and CNA staff indicated they understood that rough care and a resident not feeling safe should be treated as an abuse allegation and reported immediately, and both the DON and Administrator acknowledged that rough care and punching a wall constituted abuse that should be reported to the State within two hours. The delay in reporting and lack of timely notification to DHSS constituted the deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to facility management and within two hours to the State Survey Agency, as required by both facility policy and regulation. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and Alzheimer's disease, who required total assistance with activities of daily living. On the evening of the incident, a Certified Nurse Aide (CNA) was observed by another CNA placing a hand over the resident's mouth and telling the resident to "shut the fuck up" while the resident was crying. The witnessing CNA did not report the incident immediately but instead informed another CNA the following day, who then reported it to the Director of Nursing (DON) and the Administrator. Documentation and interviews confirmed that the facility did not report the allegation to the Department of Health and Senior Services (DHSS) until the day after the incident, exceeding the required two-hour reporting window for abuse allegations. Staff interviews revealed that employees were aware of the policy to report abuse immediately and to notify the state within two hours, but the initial witness failed to follow this protocol. There was no documentation of immediate reporting to DHSS in the resident's records, and the delay in reporting constituted a failure to comply with both facility policy and regulatory requirements.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Lack of Current Physician Order for Indwelling Catheter
Penalty
Summary
A resident with a diagnosis of neurogenic bladder had an indwelling urinary catheter in place. The physician initially ordered the discontinuation of the Foley catheter, but the resident refused, stating that the physician had not discussed the change and requested to speak with the physician first. The physician later agreed to allow the resident to keep the catheter and instructed that it be changed monthly. However, a review of the resident's medical record revealed there was no current physician's order for the catheter, including details such as catheter size or the frequency of changes, despite the resident continuing to have the catheter in place and performing their own catheter care. Observations confirmed the presence of the indwelling catheter and drainage bag, and staff interviews indicated awareness of the lack of a current physician's order for the catheter or its care. The absence of an updated physician's order for the ongoing use and maintenance of the urinary catheter constituted a deficiency in providing appropriate catheter care and ensuring proper documentation as required for residents with indwelling catheters.
Failure to Notify Families of Significant Changes and Allegations of Abuse
Penalty
Summary
The facility failed to notify the families or representatives of two residents following a significant change in condition and an allegation of abuse. Resident #1, who has a diagnosis of dementia and other mental health conditions, was involved in an incident where inappropriate touching of another resident occurred. The incident was documented by RN G, but there was no record of the resident's family or representative being informed about this change in condition or the abuse allegation. The facility's investigation revealed that the incident was discussed during a manager's meeting, but neither the interim administrator nor the Director of Nursing (DON) were initially informed. Additionally, the investigation showed that the families of both Resident #1 and Resident #2 were not notified of the incident. Resident #2, who has a durable power of attorney invoked, was also involved in the incident, but their representative was not informed of the potential abuse. Interviews with various staff members, including LPNs, the Social Services Director, and the interim administrator, confirmed that the families should have been notified of the incident. However, there was a lack of communication and documentation regarding the notification process. The facility did not have a policy in place for notifying resident representatives, which contributed to the oversight in communication.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of possible sexual abuse involving three residents to management and the state licensing agency, DHSS, within the required timeframe. The incidents involved inappropriate touching by one resident towards two other residents. The first incident occurred when a resident was observed putting their hands in the crotch of another resident, but the staff did not notify facility administration or DHSS immediately. The second incident involved the same resident touching another resident's groin area, which was also not reported to management or DHSS. The facility's policy requires that any allegations of abuse be reported immediately to management and within two hours to the state. However, the staff, including RN G, failed to notify the Director of Nursing (DON), Administrator, or DHSS about the incidents. The incidents were only brought to the attention of management during a meeting three days later, and the state was notified after this delay. Interviews with various staff members revealed that they were aware of the requirement to report such incidents within two hours, yet the protocol was not followed. The residents involved had various diagnoses, including dementia, depression, and cognitive communication deficits, which may have affected their ability to consent or understand the situation. Despite this, the facility did not document the incidents in the residents' medical records or take immediate action to report the allegations. The failure to report these incidents in a timely manner constitutes a deficiency in the facility's abuse prevention and reporting procedures.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility staff failed to immediately investigate a possible abuse incident when a staff member witnessed one resident touching another resident inappropriately in the groin area. The incident was observed by an Activities Assistant who heard a resident yell that the person being touched was not the spouse of the resident doing the touching. The Activities Assistant then moved the resident who was touching to the nurses' station and informed the MDS Coordinator about the incident. However, there was no documentation of an investigation being initiated or completed regarding this allegation of possible abuse. The facility's policies on abuse and neglect, as well as the abuse prevention program, require that all allegations of abuse be investigated and reported within the required timeframes. Despite these policies, the staff did not document any investigation into the incident involving the two residents. Interviews with various staff members, including nurse aides, LPNs, the DON, and the Administrator, revealed that they were not aware of the incident and that no investigation had been conducted. The residents involved in the incident had diagnoses that included dementia, depression, and cognitive impairments, which could affect their understanding and behavior. The failure to investigate the incident was a violation of the facility's policies and federal requirements, as it did not ensure the protection of residents during the investigation of alleged abuse. The lack of awareness and action by the facility's staff and administration contributed to the deficiency in handling the situation appropriately.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to maintain a comprehensive person-centered care plan for a resident who exhibited inappropriate touching behavior towards other residents. The resident, diagnosed with unspecified dementia, psychotic disturbances, and depression, had incidents of inappropriate touching documented on two occasions. Despite these incidents, the resident's care plan was not updated to reflect the changes in behavior, which is a requirement for comprehensive care planning. The first incident involved the resident touching another resident inappropriately, which was observed by staff and documented by a Registered Nurse. However, the care plan was not updated following this incident. The second incident was witnessed by an Activities Assistant, who reported it to the MDS Coordinator and RN Consultant, yet the care plan still remained unchanged. Interviews with various staff members, including CNAs, LPNs, and the Social Services Director, revealed that inappropriate behaviors should be documented in the care plan, but this was not done. The MDS Coordinator, responsible for updating care plans, acknowledged awareness of the incidents but did not update the care plan to include the resident's inappropriate behavior. The Director of Nursing and Interim Administrator were also unaware of the incidents until days later, indicating a breakdown in communication and documentation processes. The failure to update the care plan after these incidents highlights a deficiency in the facility's care planning process.
Inadequate Pain Management and Communication in LTC Facility
Penalty
Summary
The facility failed to provide comprehensive pain management for a resident with chronic pain syndrome, rheumatoid arthritis, and osteoarthritis. The resident experienced increased pain in the right knee, which was swollen, red, and warm to the touch. Despite the resident's complaints and visible symptoms, staff did not consistently document the resident's pain levels or follow up on the effectiveness of administered pain medications. The resident's pain was not adequately addressed, and there was a lack of communication with the physician regarding the resident's increased pain and the ineffectiveness of the current pain management regimen. The facility's staff did not document the administration of prescribed medications, such as Lyrica, due to the medication being unavailable. The staff failed to notify the physician or nurse practitioner about the unavailability of Lyrica, which was intended to manage the resident's chronic pain. The resident's pain levels fluctuated, reaching as high as 10 on a scale of 0 to 10, yet there was no documented follow-up or additional interventions to address the continued pain. The resident's condition worsened, leading to increased dependency on staff for activities of daily living and a request for a second medical opinion. Interviews with staff revealed that there was a lack of communication and coordination in managing the resident's pain. Staff members were aware of the resident's pain and the unavailability of Lyrica but did not take appropriate steps to resolve the issue or communicate effectively with the physician. The resident was eventually transferred to the hospital, where a fracture of the right patella was diagnosed, indicating that the pain and symptoms were not adequately addressed in the facility.
Failure to Notify Provider of Change in Resident's Condition
Penalty
Summary
The facility failed to provide care per standards of practice by not addressing and notifying the provider of a change in condition for a resident whose knees became swollen, red, warm, and painful. The resident, who had a history of rheumatoid arthritis and chronic pain syndrome, experienced a significant decline in mobility and an increase in pain, which was not promptly communicated to the physician or nurse practitioner. Despite multiple staff observations and the resident's requests for medical attention, the necessary notifications and interventions were delayed. The resident's condition deteriorated over several days, with staff documenting the resident's inability to bear weight, increased pain, and changes in activities of daily living (ADLs). Various staff members, including CNAs and RNs, noted the resident's knee was swollen, red, and warm to touch, yet there was a lack of timely communication with the resident's healthcare provider. The resident expressed a desire for a second opinion and was eventually transferred to the hospital, where a fracture of the right patella was diagnosed. Interviews with facility staff revealed a breakdown in communication and documentation regarding the resident's condition. Several staff members assumed the resident was on the physician's list for evaluation, but there was no clear documentation of when or if the physician was notified of the resident's worsening condition. The facility's failure to have a policy related to change of condition contributed to the delay in appropriate medical intervention, resulting in the resident's transfer to the hospital for surgical repair.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight for a resident with a history of wandering and elopement attempts. The resident, who had severe cognitive impairment and was assessed as a high risk for elopement, was not adequately monitored despite having an electronic monitoring device. On the day of the incident, the resident attempted to leave the facility multiple times, triggering alarms, but was not placed on 15-minute checks or given increased supervision as per the facility's policy. The resident was last seen in the common area by staff at 8:00 P.M. and was later found missing during rounds. Despite the resident's known history of exit-seeking behavior and verbalizing intent to leave, staff did not implement new interventions or ensure all working staff were aware of the resident's elopement risk. The facility's investigation revealed that the resident was able to leave the premises and was found in a nearby cornfield, approximately 100 yards from the facility, after a search involving law enforcement. Interviews with staff indicated a lack of consistent communication and adherence to the facility's elopement policy. Staff were aware of the resident's behaviors but did not consistently apply the necessary checks or communicate effectively about the resident's risk. The facility's systems for monitoring and responding to elopement risks were not effectively utilized, leading to the resident's unsupervised departure from the facility.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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