Willowcreek Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 250 New Florissant Road South, Florissant, Missouri 63031
- CMS Provider Number
- 265607
- Inspections on file
- 33
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Willowcreek Wellness & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to accurately document physician-ordered wound treatments on the TAR for three residents with multiple comorbidities, including anemia, diabetes, renal disease, stroke, malnutrition, and lung disease. For one resident, daily and PRN dressings to the buttocks and foot had blank TAR entries on a day when dressings were observed with dates not matching the treatment schedule, and a wound nurse reported the last change had occurred two days earlier. For another resident with a sacral wound, the bandage date did not align with the TAR, which contained multiple blank entries for the sacral treatment. A third resident’s ordered daily and PRN wound care to the left inner thigh and stump also had a missed documentation opportunity. Despite facility policies requiring clear, accurate nursing documentation and expectations from the DON, Regional Nurse, and Administrator for real-time charting using computers on carts, interviews and record review showed incomplete or missing documentation of these wound treatments, and one wound nurse described a culture of clocking out after eight hours even if wound care was not finished.
A resident who was cognitively intact, dependent on staff for personal hygiene, and frequently incontinent of urine and always incontinent of bowel repeatedly requested incontinence care using the call light but was told by staff to wait for the next shift and that they were not the assigned aide. Staff entered and exited the room, turned off the call light, and did not provide care for an extended period, despite a noticeable bowel odor and the resident’s report that this happened often and caused burning discomfort. When CNAs and an LPN eventually provided care, they found a large amount of soft stool on the resident’s buttocks and pushed into a wound dressing before completing hygiene and wound care, contrary to the facility’s perineal care policy and the resident’s ADL care plan.
A resident with vertebral osteomyelitis and a left arm PICC line for IV antibiotics had a physician order for central line dressing changes every seven days and as needed, but treatment administration records for two consecutive months showed no documented PICC dressing changes. The resident and a parent reported that the dressing had only been changed once since admission when it was already coming loose, and at the time of surveyor observation the PICC dressing was hanging loosely and could be lifted almost to the insertion site while antibiotics were infusing. The Nurse Consultant/Interim DON stated that PRN dressing changes do not alter the scheduled due date and that loose or failing dressings should be cleaned and replaced, indicating staff did not follow the ordered schedule or maintain dressing integrity.
A resident with muscle weakness, needing assistance with personal care, had a Stage 3 coccyx pressure ulcer and a physician’s order for daily and PRN wound care including cleansing, drying, application of Santyl, and placement of calcium alginate ag with a dry dressing. During a dressing change after the wound dressing became soiled, an LPN cleansed the wound, packed it with calcium alginate, and covered it with bordered gauze but did not apply Santyl as ordered. The facility’s wound management policy required necessary treatment and services for wounds, and the Nurse Consultant/Interim DON confirmed that even non-routine dressing changes should include the full ordered treatment.
The facility failed to clarify and implement diabetic monitoring and insulin orders for two residents. One resident with diabetes and kidney failure had a hospital order for PRN insulin aspart but no corresponding order for blood glucose monitoring, no documentation of insulin administration over several months, and no care plan documentation of refusals for accuchecks or insulin. Another resident with diabetes and multiple comorbidities had a critically elevated blood glucose, after which the MD ordered specific insulin doses and a repeat accucheck within two hours, but the next documented blood sugar check did not occur until the following morning. Leadership interviews confirmed that staff were expected to follow physician orders and policies, that refusals were not care planned, and that follow-up on MD orders by nursing leadership was lacking.
A resident with chronic pain did not receive prescribed oxycodone as ordered on multiple occasions due to delays in medication reordering and pharmacy delivery. Staff documented medication unavailability and offered alternative interventions, which the resident refused. The resident experienced severe pain, resulting in repeated calls to EMS and hospital transfers for pain relief. Facility staff and leadership acknowledged issues with medication ordering processes and communication, leading to lapses in pain management.
Two residents with histories of substance abuse were repeatedly allowed to leave the facility on LOA and return while intoxicated, resulting in multiple overdoses within the facility that required Narcan administration and hospitalizations. The facility did not follow its own policies for behavior management and substance abuse, failed to provide timely referrals to local resources, and did not adapt care plans or behavior contracts in response to ongoing substance use and behavioral incidents. Staff reported unclear guidance and insufficient training on managing substance abuse cases.
A resident with significant mobility impairments and a care plan requiring two-person assistance for bed mobility was left unattended in a raised bed by a CNA, who stepped away to change gloves. The resident fell from the bed, sustaining a femur fracture and shoulder contusion, and reported feeling traumatized by the event. Staff interviews confirmed the resident's need for two-person assistance and that the care plan was not followed, resulting in neglect and physical harm.
A resident who returned from the hospital after a fall and fracture exhibited symptoms such as vomiting, lethargy, and decreased responsiveness, which were documented by staff but not fully communicated to the physician as required by facility policy. The resident continued to decline and was only sent to the hospital after becoming unresponsive, where they expired shortly after arrival. Additionally, another resident did not receive wound care as ordered on multiple days, leading to worsening of a venous ulcer.
Staff failed to follow infection prevention protocols during wound care for three residents, including not performing hand hygiene before and after care, not changing gloves between tasks, and not using gowns as required by Enhanced Barrier Precautions. These lapses occurred despite facility policies and staff knowledge of proper procedures.
A resident with cognitive intactness and physical impairments reported rough treatment by a CNA during a transfer, resulting in pain and injury. The facility failed to document the grievance, conduct a thorough investigation, or provide the resident with findings or resolution, and did not ensure the resident's satisfaction with the outcome. Staff interviews revealed inadequate follow-up and lack of proper documentation throughout the grievance process.
A resident with cognitive intactness and physical impairments alleged that a CNA handled them roughly during a transfer, but the facility did not complete a thorough abuse investigation as required by policy. Documentation was incomplete, lacking a resident statement, investigation summary, Ombudsman notification, and proper reporting. Leadership classified the incident as a customer service issue rather than abuse, resulting in the facility not following its abuse investigation procedures.
A resident with a history of mood and behavioral disorders repeatedly engaged in verbal aggression, bullying, and use of racial slurs toward peers, causing others to avoid communal areas. Despite ongoing incidents and complaints from residents and staff, the facility failed to implement effective behavior management, update care plans, or consistently notify the physician or psychiatric providers, resulting in a deficiency in abuse prevention and resident rights.
A resident with a history of depression, PTSD, and personality disorder repeatedly exhibited verbal aggression, cursing, and threats toward staff and peers. Facility staff did not implement a comprehensive behavioral management program, failed to consistently notify the physician or psychiatric providers after incidents, and did not provide ongoing assessment or IDT follow-up. The lack of effective interventions led to other residents feeling bullied and avoiding communal spaces, with no documented facility response to resident council concerns.
The facility did not consistently provide written responses to concerns raised by residents during Resident Council meetings, including repeated complaints about bullying and intimidation by another resident. Despite policies requiring prompt written follow-up, staff and administration confirmed that responses were not always completed or communicated back to the Council.
A facility failed to consistently monitor and address ongoing disruptive verbal behaviors of a resident, as required by its QAA policy. Despite repeated incidents of verbal aggression and complaints from staff and residents, documentation showed that the QAA Committee only addressed the issue in two out of four consecutive months, resulting in a lack of ongoing evaluation and follow-up.
A resident reported that an unknown female staff member with braids threatened physical harm. The facility did not promptly or thoroughly investigate the allegation as required by its abuse prevention policy. Key staff were not interviewed in a timely manner, and staff matching the description continued to work before being cleared. The Administrator acknowledged not following the facility's investigation procedures.
A resident with multiple medical conditions reported to facility leadership that a staff member verbally threatened them with physical harm. Although the incident was promptly reported internally, the facility failed to notify the State Survey Agency within the required two-hour timeframe as mandated by policy.
A resident with a history of high blood pressure and malnutrition was not monitored for weight weekly as recommended, and the facility failed to notify the physician when blood pressure medication was held due to low readings. The resident's condition worsened, leading to hospitalization. Interviews revealed that staff did not follow protocol for notifying the physician or reassessing the resident's condition.
The facility failed to obtain and record weekly weights for three residents experiencing weight loss, as ordered by the RD. This deficiency was due to inconsistent weight documentation and lack of communication with the RD. Residents with cognitive impairments and other health issues experienced significant weight loss, and staff interviews revealed issues with dietary orders and weight monitoring. The DON admitted to being behind on entering weights into the EMR, and dietary aides reported changes in portion sizes since new ownership.
The facility failed to provide care consistent with professional standards, including lack of physician orders for a resident's radiation therapy, incomplete wound treatments for another resident, and inadequate repositioning for a bedbound resident. Additionally, a resident on continuous oxygen therapy lacked necessary physician orders. Staff interviews revealed gaps in communication and adherence to protocols.
The facility failed to maintain proper documentation and management of resident personal funds after a change in ownership, affecting 61 residents. The BOM lacked access to the electronic accounting system and resident trust bank statements, leading to estimated fund disbursements. The Administrator confirmed the issue, with the new ownership working on a resolution.
A facility failed to maintain complete medical records for 11 residents, including medication administration and various assessments, due to a recent ownership change. This change resulted in the loss of access to the EMR system, leading to incomplete documentation and uncertainty among staff about assessment requirements. Interviews with staff revealed that critical documentation was lost, contributing to the deficiency.
The facility failed to maintain a homelike environment, with issues such as damaged walls, leaking toilets, and unclean rooms persisting despite being reported by residents. Observations revealed unclean dining areas and blocked shower rooms. Interviews indicated a lack of communication and reporting, with maintenance unaware of several issues due to a malfunctioning reporting system.
The facility failed to adhere to tube feeding protocols, resulting in inadequate nutritional support for residents. Observations showed that tube feeding was not administered as per physician orders, with issues such as unlabeled formula bags, incorrect feeding rates, and failure to replace empty containers. Interviews with staff revealed a lack of understanding and adherence to feeding schedules, compromising resident care.
The facility failed to provide adequate dialysis care for residents, lacking physician orders and documented assessments. Four residents receiving dialysis had deficiencies, including missing orders for dialysis and site monitoring, and absent pre and post-dialysis evaluations. Staff interviews revealed inconsistencies in obtaining and documenting orders, exacerbated by a recent change in ownership that disrupted the electronic medical record system.
The facility failed to properly assess and document the use of bed rails for several residents, lacking physician orders, assessments, and consents. Observations confirmed side rails in use without necessary documentation, revealing systemic issues in policy adherence. Staff interviews highlighted confusion in roles and processes, exacerbated by recent ownership changes.
The facility failed to provide bedtime snacks to residents, as confirmed by observations and staff interviews. Residents reported that evening snacks had stopped being offered weeks ago. Staff indicated that snacks were only available during the day shift, and the practice of placing snacks at nurse's stations for the evening shift had ceased. The Dietary Manager noted that snacks were intended to be provided at night, but issues arose with nursing staff consuming them. Both the DON and Administrator were unaware of the deficiency.
A resident was found with unattended medications at their bedside without a physician's order for self-administration in an LTC facility. The resident, who required assistance with daily activities, confirmed that staff regularly left medications for self-administration. Interviews with staff, including an LPN and the DON, indicated that no residents were authorized to self-administer medications, and medications should not be left unattended without a physician's order.
The facility failed to meet the ADL care needs for three residents, resulting in deficiencies in personal hygiene and grooming. A resident with severe cognitive impairment did not receive scheduled showers, leading to oily hair and dried matter around the mouth. Another resident had long nails with dark matter underneath, indicating a lack of hygiene care. A third resident expressed discomfort with an untrimmed beard, which was not addressed despite their request. Interviews revealed an expectation for staff to assist with all ADL care needs, which was not met.
A resident with a Stage Three pressure ulcer did not receive necessary treatments as ordered, leading to a deficiency in care. The resident's dressing was not changed daily as required, and the wound showed no improvement. Staff interviews confirmed that the facility's protocol for informing the next shift of incomplete treatments was not followed, resulting in inaccurate documentation.
A resident with anoxic brain injury and quadriplegia did not receive the prescribed right-hand wrist splint as required. Observations showed the resident without the splint, and documentation was incomplete. Staff interviews revealed that the RA responsible for applying the splints was often unavailable, and other nursing staff did not consistently fulfill this duty. The DON confirmed that splints should be applied per orders and documented accurately.
A facility failed to maintain physician orders for colostomy care for a resident with a colostomy, hypertension, cardiac arrhythmia, cerebral infarction, and quadriplegia. The resident did not receive regular colostomy care, resulting in a full and pressurized colostomy bag. Staff interviews confirmed the need for routine care, but difficulties in accessing physician orders due to a corporate changeover led to the deficiency.
Two residents with specific needs for assistive eating devices were not provided with the necessary equipment, such as divided plates and built-up utensils, leading to difficulties in eating and food spillage. Staff interviews revealed a lack of awareness and documentation regarding the residents' needs, resulting in the deficiency.
The facility failed to notify the State LTC Ombudsman of resident transfers and discharges since April 2024. The SSD, responsible for these notifications, could not access old emails due to a change in ownership. The Administrator was unaware of the issue, which was exacerbated by email system problems that prevented notifications from being sent.
Failure to Accurately Document Physician-Ordered Wound Treatments on TAR
Penalty
Summary
The deficiency involves the facility’s failure to accurately document physician-ordered wound treatments on the Treatment Administration Record (TAR) for multiple residents, contrary to its own policies requiring concise, clear, and accurate nursing documentation. For one resident with anemia, diabetes, and lung disease, physician orders directed daily and PRN dressing changes to a right posterior buttocks wound and a right foot wound. The March TAR for this resident showed blank documentation entries for both wound treatments on a specific date. Observations showed the right leg and foot dressing dated two days prior, while the coccyx dressing was dated the day before, and the wound nurse who worked the prior night reported last changing the right foot dressing two days earlier. Another resident with anemia, hyponatremia, hip fracture, malnutrition, and lung disease had a physician order for daily or PRN sacral wound care. Observation showed the sacral bandage dated the previous day, and review of the March TAR revealed multiple blank entries for the sacral wound, including no documentation of a dressing change on the date corresponding to the bandage date. A third resident with anemia, renal disease, stroke, malnutrition, and lung disease had a physician order for daily and PRN wound care to the left inner thigh and left stump, but the March TAR showed one of three opportunities left blank. The facility’s Wound Management policy required weekly documentation of treatment effectiveness by an LPN or RN, and the Documentation – Nursing Policy prohibited falsification or improper correction of nursing documentation and required accurate, evidence-based charting. During interviews, one wound nurse stated there were no residents missing treatments and described a culture of clocking out after eight hours even if wound care was unfinished. The DON, Regional Nurse, and Administrator each stated they expected all treatments to be documented at the time they were completed, with nurses using computers on carts to chart in real time, but the TAR reviews and observations demonstrated missing or incomplete documentation of ordered wound treatments for three residents in the sample of five.
Failure to Provide Timely Incontinence and Hygiene Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living and personal hygiene to a resident who was dependent on staff for care. The resident had diagnoses including muscle weakness and a need for assistance with personal care, was cognitively intact, frequently incontinent of urine, and always incontinent of bowel, and was care planned to require assistance with all ADLs to be properly dressed and groomed daily. Facility policy required perineal care at least once daily and as needed to maintain cleanliness, reduce odor, and prevent infection or skin breakdown. On the morning in question, surveyors observed the resident in bed with an odor of bowel movement in the room. Later that morning, the resident activated the call light and a staff member entered the room, spoke with the resident, and then told the resident they were waiting for day staff to come in, turned off the call light, and left without providing incontinence care. The resident reported that he/she had requested to be cleaned and was told to wait, stating this happened frequently and that staff often said they were not his/her aide and would not help, and that his/her bottom burned when not cleaned. Subsequent observations showed additional staff entering and exiting the room, with one staff member stating they did not know who the aide would be and another indicating they were just answering the light and did not have the resident on their assignment. The resident’s call light was turned off without care being provided until later, when CNAs and an LPN entered the room and uncovered the resident, revealing a large amount of soft bowel movement on the buttocks and pushed into the wound dressing. The CNAs then provided personal hygiene and the LPN performed wound care, and the resident stated his/her bottom was getting sore.
Failure to Follow PICC Line Dressing Change Orders and Maintain Dressing Integrity
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice when staff did not follow orders for a PICC line dressing change and did not ensure the dressing was secure. A resident with osteomyelitis of the vertebra was admitted with a PICC line in the left upper extremity for long-term IV antibiotics. The medical record included an order dated 1/15/26 for a central line dressing change every seven days and as needed. Review of the treatment administration records for January and February 2026 showed that the PICC line dressing changes were not documented as completed, and the next scheduled treatment to prompt staff to change the PICC line dressing was not set to trigger until 2/11/26. During observation and interview on 2/5/26, the resident reported being admitted with the PICC line for antibiotics and stated that the dressing had only been changed once at the facility, on 1/29/26, when it was coming off. The resident and the resident’s parent reported that the infection control doctor had said the PICC dressing needed to be changed at least weekly and that staff were not changing it. At the time of observation, IV antibiotics were infusing through the left arm PICC line, and the outer aspect of the dressing was hanging loosely. The resident demonstrated that the edge of the dressing could be lifted almost to the insertion site. The Nurse Consultant/Interim DON stated that if a dressing is changed as needed, it does not change the due date for the next treatment, and that if a treatment is loose or falling off, staff should clean the site and replace the dressing and contact the physician if there are integrity issues with the PICC line.
Failure to Follow Ordered Pressure Ulcer Treatment Regimen
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment for a resident with a Stage 3 coccyx pressure ulcer. The resident had diagnoses including muscle weakness and a need for assistance with personal care, and had a physician’s order dated 1/8/26 to cleanse the coccyx area with normal saline/Vashe, pat dry, apply Santyl, then apply calcium alginate ag and cover with a dry dressing daily and as needed. The facility’s wound management policy required that residents with wounds receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries. Review of the wound report showed the resident had a Stage 3 coccyx pressure ulcer during the review period. On observation, an LPN changed the resident’s soiled coccyx dressing by cleansing the wound with wound cleanser, packing it with calcium alginate, and covering it with bordered gauze, but did not apply Santyl as ordered. In an interview, the Nurse Consultant/Interim DON stated that when a dressing is changed at a non-routine time due to soiling, staff should still apply the treatment as ordered.
Failure to Clarify and Implement Diabetic Monitoring and Insulin Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure diabetic care and physician orders were implemented and clarified according to professional standards. For one resident with diabetes and kidney failure, the hospital after-visit summary ordered insulin aspart 6 units subcutaneously every eight hours PRN, but there was no corresponding physician order in the facility record to check the resident’s blood sugar. The resident’s care plan identified risk for abnormal blood sugars and included diabetes medication as ordered, but did not address refusals of blood sugar checks or insulin administration. Medication administration records from May 2025 through January 2026 showed no documentation that insulin aspart was administered during that period. The Medical Director stated he expected staff to check the resident’s blood sugars twice daily and administer insulin aspart for elevated blood sugars, and the ADON acknowledged staff should have clarified the hospital orders. For another resident with diabetes, morbid obesity, obstructive sleep apnea, hepatitis C, and altered mental status, the facility had physician orders for insulin lispro per sliding scale every eight hours PRN and insulin glargine 20 units subcutaneously at bedtime. A progress note documented that the resident’s blood glucose was 484, and the Medical Director ordered 24 units of Lantus, 12 units of Lispro, and a follow-up accucheck within two hours. However, the next documented blood sugar check did not occur until the following morning, with a blood glucose level of 113, and there was no documentation of any blood sugar check between the time of the elevated reading and the next morning. Interviews with facility leadership confirmed expectations that staff follow physician orders and facility policies. The Medical Director stated he was unaware whether there was an order for accuchecks for the first resident and noted that refusals made it difficult to obtain blood sugars and administer insulin, and he did not believe those refusals were care planned. The ADON stated that staff should follow policy and that CMTs could assist with accuchecks and insulin administration when nurses were behind, and the Administrator stated that the DON and ADONs should follow up on all orders written by the Medical Director. These findings show that physician orders were not clarified or fully implemented and that ordered monitoring of blood glucose was not completed as directed.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
The facility failed to ensure that a resident with chronic pain received pain medication as ordered, resulting in multiple instances where the resident experienced severe pain due to unavailability of prescribed oxycodone. The resident, who had diagnoses including discitis, chronic pain, post-polio syndrome, and muscle weakness, was prescribed oxycodone 20 mg four times daily. Despite this, there were repeated occasions documented in the Medication Administration Record (eMAR) and progress notes where the medication was not available at the scheduled times, and the resident went without the ordered pain relief for hours or until the next day. Staff often documented that the medication was on order, awaiting delivery, or unavailable, and offered alternative interventions such as Tylenol or ibuprofen, which the resident refused due to lack of efficacy in the past. Interviews with nursing staff and facility leadership revealed that medication reordering processes were inconsistent and often delayed. Staff reported challenges with the pharmacy, including restrictions on early refills and requirements for new prescriptions with each order, which led to delays in obtaining the medication. The emergency kit (e-kit) did not always contain the correct dosage, necessitating additional physician orders and further delays. The resident was not consistently informed in advance about medication shortages and was only notified at the time the medication was due, causing distress and uncertainty about when pain relief would be available. As a result of these failures, the resident experienced multiple episodes of severe pain, leading to repeated calls to emergency medical services and hospital transfers to obtain pain relief. Documentation shows that the resident expressed frustration and distress over the unpredictability of pain management and the lack of timely communication from staff. The facility's pain management policy required timely assessment and administration of pain medication, but these procedures were not followed, directly contributing to the resident's unmanaged pain and repeated hospitalizations.
Failure to Provide Behavioral Health Services and Substance Abuse Interventions
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with histories of substance abuse, in violation of its own Behavior Management and Resident Drug and Alcohol Abuse policies. Both residents were admitted with known substance abuse issues and continued to use and abuse illegal substances while on leave of absence (LOA) from the facility. Despite multiple documented overdoses occurring within the facility, including several instances where staff had to administer Narcan to revive one resident, the facility allowed both residents to continue taking LOAs and return to the facility while intoxicated. There was a lack of consistent documentation and follow-up regarding the residents' substance use, and the care plans and behavior contracts did not adequately address or adapt to the ongoing non-adherence and repeated incidents. One resident had a documented history of opioid, cannabis, and alcohol abuse, and was admitted for rehabilitation. This resident experienced multiple overdoses within the facility, requiring emergency interventions and hospitalizations. The facility's records show repeated LOAs, sometimes for days, with the resident returning in an impaired state. Despite these events, the care plan interventions were limited to encouraging counseling and re-education on the facility's drug policy, with no evidence of effective interdisciplinary team (IDT) collaboration or revision of the care plan in response to ongoing substance use. The facility also failed to consistently document drug screenings and did not provide timely or effective referrals to local substance abuse resources. The second resident, also with a history of psychoactive substance abuse, was admitted with an ankle monitor and had multiple hospitalizations for overdose and severe intoxication. This resident made threats of violence and exhibited inappropriate behaviors toward staff, yet was still permitted to leave the facility and return while intoxicated. The facility's response did not include effective behavioral health interventions or consistent monitoring, and there was insufficient documentation of IDT involvement or adaptation of the care plan to address the resident's ongoing substance abuse and behavioral issues. Staff interviews revealed a lack of clear direction and training on managing residents with substance abuse problems, and the facility did not follow its own policies regarding assessment, intervention, and provision of local resources for substance abuse treatment.
Neglect Resulting in Resident Fall and Injury Due to Failure to Follow Care Plan
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide necessary services to a resident with significant mobility limitations, resulting in neglect and physical harm. The resident, who had a history of stroke with right-side hemiplegia, an above-the-knee amputation, muscle wasting, dementia, and was assessed as totally dependent on staff for personal hygiene and bed mobility, was left unattended in a raised bed. The CNA left the resident alone to change gloves, during which time the resident fell from the elevated bed onto the floor. The resident sustained a closed fracture of the right femur and a contusion to the left shoulder as a result of the fall. The resident reported feeling scared and traumatized by the event, as documented in a trauma screen and social work notes. The care plan for the resident specified the need for substantial or maximal assistance, including two-person assistance for bed mobility and personal care, which was not followed at the time of the incident. Interviews with staff confirmed that the resident required two-person assistance and that it was not acceptable to leave such a resident unattended, especially with the bed in a high position and without bedrails in place. Further review of facility policies indicated that staff were trained and expected to follow individualized care plans and provide adequate supervision to prevent neglect and physical harm. The CNA involved was suspended and subsequently terminated for violation of safety rules and failure to follow the care plan. There were also unsubstantiated reports from staff regarding possible impairment of the CNA while on duty. The incident was reported as neglect due to the failure to provide the required level of assistance and supervision, directly resulting in the resident's injury.
Failure to Notify Physician and Follow Orders After Change in Condition
Penalty
Summary
The facility failed to follow its policy for change of condition notification and physician order compliance when a resident experienced a significant decline after a fall resulting in a femur fracture and shoulder contusion. After returning from the hospital, the resident was discharged with instructions to monitor for symptoms such as vomiting, lethargy, and confusion, which would require immediate medical attention. Despite documentation of these symptoms, including vomiting, lethargy, sweating, increased blood pressure, and elevated blood sugar, the facility did not notify the physician of all these changes, nor did they send the resident to the hospital in a timely manner. The resident continued to decline, exhibiting decreased oral intake, increased lethargy, inability to take oral medications, and eventually became unresponsive before being sent to the hospital, where the resident expired shortly after arrival. Interviews with staff revealed a lack of awareness and communication regarding the resident's after-visit hospital summary and the specific symptoms that should have prompted immediate action. Several LPNs and the ADON indicated they were either unaware of the discharge instructions or did not review the 24-hour report thoroughly. The DON and Interim DON both stated that staff should have notified the physician and sent the resident out when the change in condition was observed, regardless of the physician's initial reluctance. The medical director also confirmed that staff should have reported the resident's dropping blood pressure, as it could not be managed in the facility. Additionally, the facility failed to ensure physician orders for wound care were followed for another resident with a venous ulcer. The treatment administration record showed multiple days where the ordered wound care was not completed or documented. This failure to provide necessary wound care as ordered contributed to the resident's wound worsening over time, as documented in the wound reports. Both deficiencies were identified during the survey, with the first resulting in an Immediate Jeopardy finding.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to established infection prevention and control protocols during wound care for three residents. Observations revealed that staff did not perform hand hygiene before donning gloves, upon entering or exiting resident rooms, or between critical steps of wound care such as removing soiled dressings, cleaning wounds, and applying new dressings. Staff also neglected to change gloves between dirty and clean tasks, and did not consistently use gowns as required by Enhanced Barrier Precautions (EBP) for residents with wounds. For one resident with heart failure, malnutrition, and quadriplegia, an LPN prepared wound care supplies, applied gloves without prior hand hygiene, and entered the room without a gown. The LPN removed a soiled dressing, during which a piece of skin tissue detached, cleansed the area, and applied a new dressing without changing gloves or performing hand hygiene. The LPN then exited the room without sanitizing hands. Similar lapses were observed with two other residents: one with severe cognitive impairment and an arterial ulcer, and another with moderate cognitive impairment, diabetes, and a surgical wound. In both cases, the LPN failed to perform hand hygiene at required intervals, did not change gloves between tasks, and did not use a gown as required by EBP. Interviews with staff and the Director of Nursing confirmed that the expected practice is to use gowns and gloves for EBP during high-contact care, and to perform hand hygiene before and after treatments, as well as between glove changes. However, the observed practices did not align with these expectations or the facility's written policies, resulting in a failure to follow acceptable standards of infection control for residents requiring wound care.
Failure to Follow Grievance Policy and Resolve Resident Complaint
Penalty
Summary
The facility failed to follow its grievance policy and maintain an effective process for residents to voice and resolve grievances. A resident, who was cognitively intact and had upper extremity impairment, anemia, and renal insufficiency, reported that a CNA treated them roughly during a transfer to the restroom, resulting in pain and injury. The resident stated that the CNA insisted they stand up despite their request for a lift, stomped on their feet, and pushed them onto the toilet, causing the resident to fall back and hurt their back. The resident reported the incident to multiple staff members, including nurses and the administrator, but did not receive timely feedback or resolution regarding their complaint. The facility's grievance log did not document the resident's complaint, and the investigation report lacked essential information such as the date and time the grievance was received, a summary of findings, and whether the grievance was confirmed. There was no written account from the resident included in the investigation, and no documentation of steps taken to prevent further violations during the investigation. The facility also failed to provide the resident with a summary of the findings or inform them of any corrective actions taken. The resident was not asked if they were satisfied with the outcome, and there was no documentation of their right to appeal the results. Interviews with staff revealed inconsistencies in the handling of the grievance. The ADON and Social Service Director acknowledged the resident's concerns but did not ensure proper follow-up or documentation. The CNA involved was removed from the resident's floor but continued to work in the facility, and there was no evidence of required training or disciplinary action being documented. The resident continued to experience pain and felt that their concerns were not addressed, expressing frustration at the lack of communication and resolution.
Failure to Investigate Alleged Abuse per Facility Policy
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident who was cognitively intact, had upper extremity impairment on one side, used a wheelchair, and had diagnoses of anemia and renal insufficiency. The resident reported that a certified nurse assistant (CNA) slammed them into the restroom and forced them to stand up despite their request for a lift, resulting in the CNA slamming the resident's leg against their foot. The facility's documentation included a grievance/complaint report and some progress notes indicating that the resident was upset and that the facility intended to start an investigation. However, there was no written statement from the resident about the alleged incident, and the documentation lacked a summary, conclusion, or findings of the investigation. Review of the facility's investigation materials revealed significant omissions. There was no completed Abuse Investigation Reporting Form, no summary of action steps taken, no documentation of notification to the Ombudsman, and no notification of investigation results to appropriate agencies. The investigation file only included a corrective action memo for the CNA, an employee written statement, and records of in-service training, but none of the in-service documentation showed that the CNA involved received the training. Additionally, there was no documentation of the CNA's suspension or reassignment, and no evidence that the required abuse investigation procedures outlined in the facility's policy were followed. Interviews with facility leadership confirmed that the incident was not investigated as abuse. The Executive Director and Acting DON determined the event was a customer service issue rather than abuse, and therefore did not follow the facility's abuse investigation policy. The Executive Director and Regional Nurse Consultant both stated that all allegations of known or suspected abuse should be fully investigated and documented, but this did not occur in this case.
Failure to Protect Residents from Ongoing Verbal Abuse and Bullying
Penalty
Summary
The facility failed to protect residents from abuse by not adequately addressing ongoing aggressive and abusive behaviors exhibited by a resident. This resident repeatedly yelled, cursed, threatened, and used racial slurs toward other residents, which led to other residents avoiding activities and the dining room to escape the abusive environment. Despite multiple documented incidents of verbal aggression, bullying, and intimidation, the facility's interventions were limited to verbal redirection and education, with no evidence of comprehensive behavior management or consistent notification to the resident's physician or psychiatric providers following these episodes. The resident in question had a history of depression, PTSD, personality disorder, and substance use in remission, and was cognitively intact. The care plan identified mood and behavior problems, but interventions remained largely unchanged despite the persistence and escalation of the resident's behaviors. There was no documentation of ongoing assessment, monitoring, or evaluation of the effectiveness of the behavior management program, nor were new interventions implemented in response to repeated incidents. Additionally, the facility failed to consistently notify the interdisciplinary team, physician, or psychiatric nurse practitioner after behavioral episodes, and there was a lack of follow-up or modification of the care plan to address the ongoing risk to other residents. Resident Council meeting minutes and progress notes indicated that multiple residents and staff reported concerns about the abusive behavior, including bullying, cursing, and taking cigarettes, yet there was no documented facility response to these concerns. The facility's policies required prompt reporting, investigation, and intervention in cases of resident-to-resident altercations, but these procedures were not followed. The lack of effective intervention and failure to protect residents from ongoing abuse resulted in a deficiency related to resident rights and abuse prevention.
Failure to Provide Behavioral Health Services and Implement Behavior Management Program
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who exhibited frequent verbal aggression, cursing, and threats toward both staff and other residents. Despite the resident's ongoing disruptive behaviors, staff did not develop or implement a comprehensive behavioral management program as outlined in the facility's own policy. There was a lack of ongoing assessment, monitoring, and evaluation of the effectiveness of any behavioral interventions or psychoactive medications. Documentation showed repeated incidents of verbal aggression and intimidation, but interventions were limited to verbal redirection and education, with no evidence of individualized or escalating care strategies. Staff did not consistently notify the resident's physician, psychiatrist, or psychiatric nurse practitioner following behavioral incidents, as required by policy. There was also no consistent follow-up by Social Services or the interdisciplinary team (IDT) after behavioral episodes. The care plan was not updated with new interventions in response to the resident's continued behaviors, and there was no evidence of ongoing counseling or behavioral health support sessions. The resident's behaviors were documented in the medication administration record, but there was no corresponding documentation of communication with medical providers or psychiatric consultants regarding these incidents. The resident's actions negatively impacted the psychosocial well-being of other residents, with reports of residents feeling bullied, intimidated, and avoiding communal activities and dining areas to escape the disruptive behavior. Resident Council meeting minutes documented concerns about the resident's bullying and aggressive conduct, but there was no documented facility response or evidence that these concerns were addressed through the grievance process or quality assurance review. The facility's failure to implement its own behavior management policy and to ensure timely, coordinated interventions contributed directly to the ongoing distress and compromised safety of residents and staff.
Failure to Respond to Resident Council Concerns in Writing
Penalty
Summary
The facility failed to consistently address and respond in writing to concerns raised during Resident Council meetings, as required by its own policies. Specifically, meeting minutes from two separate Resident Council meetings documented repeated complaints from residents about the bullying and intimidating behaviors of another resident, including threats, name-calling, and theft of cigarettes. Despite these concerns being formally recorded, there was no documented written response from the facility to the Resident Council regarding these issues. Interviews with the Resident Council President and the Activity Director confirmed that concerns raised during the meetings were not always addressed or responded to in a timely manner, and the required follow-up process was not completed. The Administrator was unaware that responses had not been provided for the concerns raised in the meetings. This lack of response and follow-through was contrary to the facility's policy, which mandates prompt written responses to Resident Council concerns and documentation of resolutions.
Failure to Consistently Address and Monitor Disruptive Resident Behaviors in QAA Program
Penalty
Summary
The facility failed to follow its Quality Assessment & Assurance (QAA) Program policy by not providing ongoing monitoring and evaluation of a resident with frequent disruptive verbal behaviors. The QAA Committee meeting minutes for four consecutive months were reviewed, and it was found that the resident's behaviors were only addressed in two of those months, despite ongoing incidents. The facility's policy requires an ongoing, facility-wide QAPI program to monitor, evaluate, and resolve identified problems, but documentation showed gaps in addressing the resident's behavioral issues. The resident in question had a history of mood problems, depression, and behavioral issues such as speaking rudely to peers, eating off other residents' plates, and being verbally aggressive and disrespectful to staff. The care plan included interventions like behavioral health consults, communication about mood and behaviors, and monitoring of behavioral episodes. Despite these interventions, behavior tracking records showed multiple instances of verbal aggression and disrespectful behavior over several months. Resident Council meeting minutes and medication administration records further documented ongoing complaints from both staff and residents about the disruptive behaviors. However, QAA Committee meeting minutes for two of the four months did not include any documentation that the resident's behaviors were discussed or addressed, indicating a lack of consistent monitoring and follow-up as required by the facility's QAA policy.
Failure to Promptly Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not promptly and thoroughly investigating a resident's allegation of abuse. A cognitively intact resident, with no psychiatric or mood disorders and a history of renal insufficiency, peripheral vascular disease, atrial fibrillation, and coronary artery disease, reported that an unknown female employee with braids threatened to have her brothers come to the facility and physically harm the resident. The resident reported this incident to the Social Service Director (SSD), who immediately involved the Administrator and Assistant Director of Nursing (ADON). The resident was able to describe the staff member and stated they could identify her if seen again. Despite the policy requiring prompt and thorough investigation of abuse allegations, the Administrator did not initiate interviews with other staff or residents regarding the allegation on the day it was reported. The facility's abuse policy outlines specific steps for investigation, including interviewing all relevant parties and protecting residents during the process. However, the Administrator only started a 'soft file' and delayed the investigation, waiting to see if the resident could identify the staff member in the future. The SSD and ADON also did not receive directives to begin an investigation and instead maintained a soft file, pending further identification by the resident. Additionally, staff members who matched the description provided by the resident were not immediately interviewed or suspended as required by the facility's policy. One LPN with braids worked a shift with the resident after the allegation was made but was not interviewed or identified to the resident prior to starting work. The Administrator acknowledged that the investigation was not conducted according to policy and that he was responsible for the failure to follow the required procedures.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to follow its Abuse Prevention and Prohibition policy by not notifying the State Survey Agency within two hours after a resident reported an allegation of verbal abuse by an unknown female employee. The resident reported to the Administrator, Assistant Director of Nursing (ADON), and Social Service Director (SSD) that an employee with braids threatened to have her brothers come to the facility and physically harm the resident. This report was made to facility leadership on a Thursday afternoon, but the required notification to authorities was not completed as outlined in the facility's policy. The facility's policies clearly define abuse, including verbal and mental abuse, and require immediate reporting of suspected abuse to the state agency within two hours if the allegation involves abuse or results in serious bodily injury. Despite these requirements, the Administrator, who was new to the position and had not yet reviewed the abuse reporting policy, did not report the incident to the Department of Health and Senior Services. The resident was able to communicate clearly, was cognitively intact, and had no psychiatric or behavioral issues documented at the time of the incident. The incident involved a resident with multiple medical diagnoses, including renal insufficiency, peripheral vascular disease, atrial fibrillation, and coronary artery disease. The resident described the threatening statement made by the employee and reported the event promptly to facility leadership. However, the facility did not take the required action to report the allegation to the appropriate authorities within the mandated timeframe.
Failure to Monitor Weight and Notify Physician of Low Blood Pressure
Penalty
Summary
The facility failed to monitor a resident's weight weekly as recommended by the Registered Dietitian and did not reassess or notify the physician when the resident experienced low blood pressure for two consecutive days, leading to the holding of blood pressure medication. The resident, who had a history of high blood pressure, diabetes, Alzheimer's disease, malnutrition, and dementia, was supposed to have weekly weights recorded for four weeks following a recommendation on 9/26/24. However, the facility did not document weights for three of the four weeks, and there was no notification to the resident's family about the weight loss or any interventions. Additionally, the resident's blood pressure readings were consistently low on 10/4/24 and 10/5/24, leading to the holding of Amlodipine Besylate, a medication for hypertension. Despite the facility's policy requiring notification of the physician when medication is held due to low blood pressure, the nurse did not notify the physician on the first day the medication was held. The resident's condition worsened, and on 10/13/24, the resident reported passing out, prompting a hospital transfer. Interviews with facility staff, including LPNs and the Director of Nursing, revealed that the expected protocol was not followed. The staff acknowledged that the physician should have been notified when the medication was held, and the resident's blood pressure should have been reassessed. The Director of Nursing admitted to being behind on entering weights into the electronic medical record, which contributed to the failure to monitor the resident's weight as ordered.
Failure to Monitor and Record Resident Weights
Penalty
Summary
The facility failed to obtain weekly weights as ordered by the Registered Dietician (RD) and failed to communicate with the RD that the weights were not obtained for three residents sampled for weight loss. This deficiency was identified through observation, interview, and record review. The facility's Nutrition Hydration Management policy requires residents to be weighed upon admission and re-admission, then at least weekly for four weeks, and monthly if weight is stable. However, the facility did not adhere to this policy for the residents in question. Resident #3, who has a history of diabetes, high blood pressure, malnutrition, and dementia, experienced a significant weight loss over six months. Despite orders for weekly weights, the facility failed to record weights consistently, with no weight recorded after a certain date. The resident's weight was trending down, and the RD noted a 10.1% weight loss over six months. Similarly, Resident #4, with severe cognitive impairment and other health issues, also experienced weight loss, but the facility did not document weights after a specific date, despite orders for weekly weights. Resident #5, who is tube-fed and has severe cognitive impairment, also had inconsistent weight documentation, with no weights recorded after a certain date. Interviews with facility staff revealed issues with the implementation of dietary orders and weight monitoring. The RD oversees multiple facilities and expects weights to be done as ordered, but acknowledged problems with computer changes affecting record-keeping. The Director of Nursing (DON) admitted to being behind on entering weights into the electronic medical record (EMR) and stated that the facility does not allow the management team to assist her. Additionally, dietary aides reported changes in portion sizes since new ownership, which may affect residents' nutritional intake. These actions and inactions contributed to the deficiency in maintaining residents' nutritional status as per the facility's policy.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards, as evidenced by several deficiencies. One resident, who had undergone breast cancer surgery and was receiving daily radiation therapy, did not have appropriate physician orders for the radiation treatment. The staff did not assess the resident's skin condition after the surgery or radiation treatments, and there was a lack of documentation regarding the resident's tolerance to the treatments. Interviews with staff revealed a lack of awareness and documentation regarding the resident's condition and treatment needs. Another resident with chronic vascular wounds did not receive wound treatments as ordered. The facility's wound nurse was responsible for dressing changes during weekdays, but on weekends, the responsibility fell to the charge nurse. However, there was a failure to ensure that the treatments were completed as scheduled, and documentation was inaccurately marked as completed when it was not. Interviews with staff highlighted a lack of communication and adherence to treatment protocols. Additionally, a resident who was dependent on staff for bed mobility and at high risk for skin breakdown was not routinely turned and repositioned every two hours as required. Observations showed the resident remained in the same position for extended periods, increasing the risk of pressure ulcers. Staff interviews confirmed the importance of regular repositioning for such residents, yet it was not consistently practiced. Furthermore, a resident receiving continuous oxygen therapy did not have physician orders for oxygen use and maintenance, which were necessary for proper care management. The oversight was attributed to recent changes in facility ownership and the resident's hospitalization, leading to missed orders in the electronic medical record.
Deficiency in Resident Fund Management Post-Ownership Change
Penalty
Summary
The facility failed to maintain proper documentation and management of resident personal funds following a change in ownership. This deficiency affected all 61 residents whose funds were handled by the facility. The Business Office Manager (BOM) was unable to access the electronic accounting system used to manage these funds due to the previous ownership not cooperating with the new management. As a result, the BOM could not perform monthly reconciliations or access resident trust bank statements, leading to an inability to accurately determine the amount of personal allowance each resident should receive. The BOM resorted to estimating the funds to be given to residents, as she did not have access to the necessary authorizations or records. The Administrator confirmed the lack of access to the resident trust account and fund accounting system, stating that the new ownership was working on resolving the issue but without a clear timeline. The BOM emphasized the need for access to these systems to ensure residents do not exceed their spenddown limits and to accurately process fund requests. The facility assured that any accounting errors occurring before regaining access would be covered by the facility to prevent negative impacts on the residents.
Deficient Documentation and Record Maintenance Post-Ownership Change
Penalty
Summary
The facility failed to ensure proper documentation and maintenance of medical records for 11 residents, which included medication administration and various assessments such as skin, Braden, AIMS, bed safety, smoking, elopement, and fall risk assessments. The facility's policy emphasized the importance of maintaining accurate and timely medical records to enhance resident outcomes. However, the records for these residents were incomplete, with missing documentation for vital signs, medication administration, and required assessments. The deficiencies were exacerbated by a recent change in facility ownership, which resulted in the loss of access to previously stored electronic medical records. Staff were unable to access the EMR system for several days, leading to the use of paper documentation for medication administration, which was subsequently misplaced. The new ownership did not provide guidance on the continuation of assessment protocols, leaving staff uncertain about the requirements for maintaining complete and accurate records. Interviews with facility staff, including the DON and Administrator, revealed that the change in ownership led to the disappearance of critical documentation, including signed admission paperwork and hospitalization records. The facility's inability to retrieve or access these records contributed to the incomplete documentation of resident care, as assessments and medication administration records were not properly maintained or transferred to the new EMR system.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by several observations and resident reports. Resident #85, who is cognitively intact and has a history of burn wounds, was found to have a damaged drywall strip behind their bed with debris on the floor, and a bathroom with a leaking toilet. The resident reported these issues to the nursing staff, but they persisted for months. Similarly, Resident #121, who is cognitively impaired and uses a wheelchair, also experienced a leaking toilet in their bathroom, which they reported to the nursing staff. Resident #18, who is cognitively impaired and has a colostomy, had a room with food and trash debris on the floor, along with a sticky substance causing the floor to be tacky. Resident #25, who is cognitively intact and uses a wheelchair, had a room with damaged walls and a door that would not close properly, which affected their ability to sleep due to noise. Despite reporting these issues to maintenance and other staff, the problems remained unresolved. Additional observations included a feeding assistance room with missing baseboards and a dining room with tables left uncleaned from previous meals. A shower room was found with a clogged toilet, trash on the floor, and a Hoyer lift blocking entry. Interviews with housekeeping and maintenance staff revealed a lack of communication and reporting of these issues, with the maintenance director unaware of several problems due to a malfunctioning online reporting system. The administrator expected daily cleaning and maintenance, but these expectations were not met, leading to the deficiencies observed.
Deficiencies in Tube Feeding Administration
Penalty
Summary
The facility failed to ensure that staff adhered to its policies regarding tube feeding, resulting in deficiencies in the care of residents receiving enteral nutrition. Observations and interviews revealed that the facility did not consistently follow physician orders for tube feeding, leading to inadequate nutritional intake for several residents. For instance, Resident #175 was observed without tube feeding formula hung on multiple occasions, despite orders for continuous feeding. Additionally, the formula bags were often undated and unlabeled, and the feeding was not administered as per the prescribed schedule. Resident #65 also experienced issues with tube feeding administration. Observations showed that the resident's enteral feeding was not infusing at the prescribed times, and the formula bottles were not replaced when empty, contrary to the physician's orders. The feeding rate was also incorrect, with the pump set at 65 ml/hour instead of the ordered 75 ml/hour. These discrepancies were noted over several days, indicating a pattern of non-compliance with the prescribed nutritional support plan. Similar deficiencies were observed with Residents #38 and #107, where the tube feeding was either not connected or set at incorrect rates. Interviews with nursing staff, including LPNs and the Director of Nursing, highlighted a lack of understanding and adherence to the facility's tube feeding protocols. Staff admitted to challenges in managing the feeding schedules and acknowledged that some nurses were not familiar with resetting the feeding machines properly. This lack of compliance with physician orders and facility policies compromised the nutritional support provided to the residents.
Deficiencies in Dialysis Care and Monitoring
Penalty
Summary
The facility failed to ensure proper dialysis care and monitoring for residents receiving dialysis, as evidenced by the lack of physician orders and documented assessments. Four residents were identified with deficiencies in their dialysis care, including missing physician orders for dialysis and monitoring of dialysis sites, as well as the absence of pre and post-dialysis evaluations. The facility's Hemodialysis Care and Monitoring policy did not provide adequate guidance for obtaining physician orders or conducting pre and post-dialysis monitoring. Resident #111, who was cognitively intact and diagnosed with kidney failure, had no physician order for dialysis or monitoring of the dialysis site documented in their electronic medical record. Similarly, Resident #46, who had diagnoses including heart failure and kidney failure, had no documented orders related to dialysis beyond the schedule. Resident #50, with mild cognitive impairment and multiple diagnoses, also lacked orders to check the dialysis site for signs of infection, despite having a dialysis port in the right upper chest. Resident #26, diagnosed with type 2 diabetes mellitus and end-stage renal disease, had no order to check for bruit and thrill, which are critical for monitoring vascular access. Interviews with facility staff, including LPNs and the Director of Nurses, revealed inconsistencies in the process of obtaining and documenting physician orders for dialysis, as well as conducting pre and post-dialysis assessments. The facility had recently undergone a change in ownership, which led to a transition in the electronic medical record system and confusion among staff regarding the dialysis assessment tools. The Director of Nurses acknowledged the need for physician orders to include specific details about dialysis and monitoring, but the change in ownership had disrupted the previous system, leaving the facility without a clear process for ensuring comprehensive dialysis care.
Deficiency in Bed Rail Assessment and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails for several residents, leading to a deficiency in compliance with safety protocols. Specifically, residents were not assessed for the use of side rails, and there were no physician orders, therapy or nursing assessments, or consents obtained for their use. This was observed in multiple residents, including those with significant medical conditions such as morbid obesity, acquired absence of limbs, motor-vehicle accident injuries, multiple sclerosis, Parkinson's disease, quadriplegia, and severe cognitive impairment. The facility's policy requires a comprehensive assessment of residents' needs and risks associated with bed rail use, including obtaining a physician's order and informed consent. However, the facility's records showed a lack of documentation and oversight, as several residents using side rails were not listed in the maintenance bed rail log. Observations confirmed that side rails were in use without the necessary assessments and documentation, indicating a systemic issue in the facility's adherence to its own policies. Interviews with staff revealed inconsistencies in the process of assessing and documenting the use of side rails. There was confusion about the roles of therapy and nursing in obtaining physician orders and conducting assessments. Additionally, the facility had recently undergone a change in ownership, which contributed to the lack of clarity and implementation of new policies. The Director of Nurses and the Administrator acknowledged the deficiencies and the need for clinical training to align with the new ownership's policies.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide snacks at bedtime for residents, as observed and reported by both staff and residents. During a group interview, four alert and oriented residents mentioned that the facility had stopped offering evening snacks about two to three weeks prior. Observations conducted over several days confirmed that no snacks were available at the nurse's stations on both the Serenity and Harmony halls during early morning hours. Interviews with staff, including an LPN and a CNA, revealed that snacks were only provided during the day shift, and the practice of placing snacks at the nurse's station for the evening shift had ceased. The Dietary Manager stated that snacks were supposed to be offered at night, with trays sent to each hall at 8:00 P.M., but acknowledged issues with nursing staff consuming the snacks. The DON and the Administrator were both unaware that residents were not receiving snacks at bedtime, although they expected that snacks should be provided. The Administrator mentioned a recent change in the process where snacks were placed at nurse's stations, but this was not effectively implemented, leading to the deficiency.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to adhere to its medication administration policies by leaving medications unattended in a resident's room without a physician's order for self-administration or bedside medication. The resident, who was cognitively intact but had moderately impaired vision and required assistance with daily activities, was observed with a medicine cup filled with multiple pills and a cloudy liquid on a bedside table. The resident confirmed that staff routinely left medications at the bedside for self-administration, despite not having a physician's order or a completed self-medication assessment. Interviews with facility staff, including an LPN, a CMT, and the DON, revealed that there were no residents in the facility authorized to self-administer medications. The staff acknowledged that medications should not be left unattended at the bedside without a physician's order and that they are expected to observe residents taking their medications. The facility's policies require an assessment and a physician's order for self-administration, which were not present in the resident's medical records.
Failure to Meet ADL Care Needs for Residents
Penalty
Summary
The facility failed to meet the Activities of Daily Living (ADL) care needs for three residents, resulting in deficiencies in personal hygiene and grooming. Resident #107, who has severe cognitive impairment and requires total assistance, did not receive scheduled showers or bed baths, as evidenced by oily hair and dried white matter around the mouth over several days. Despite being scheduled for showers twice a week, there was no documentation of showers being missed, indicating a lapse in care. Similarly, Resident #38, also with severe cognitive impairment, was observed with long nails and dark matter underneath, suggesting a lack of attention to personal hygiene. The responsibility for nail care was not adequately fulfilled by the staff, as confirmed by interviews with LPN A. Resident #88, who requires assistance with ADL care, expressed discomfort with the length of their beard, which was not trimmed despite the resident's request. The resident's care plan indicated a need for setup and cleanup assistance for personal hygiene, but this was not provided. Interviews with LPN A and the Director of Nursing revealed an expectation for nursing staff to assist with all ADL care needs, which was not met in these cases. The facility's failure to adhere to its policy of promoting resident-centered care and attending to the total needs of residents led to these deficiencies.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatments and services to promote healing for a resident with a pressure wound. The resident, who had moderately impaired cognition and diagnoses including heart failure, kidney failure, wound infection, and peripheral vascular disease, had a Stage Three pressure ulcer on the coccyx. The facility's policy required daily monitoring and treatment of existing wounds, but the resident's treatment was not completed as ordered on specific dates. Observations revealed that the resident's coccyx dressing, which should have been changed daily, was not changed for several days. The wound nurse, responsible for dressing changes Monday through Friday, noted that the wound showed no improvement and that the dressing had not been changed as required. On weekends, the responsibility for dressing changes fell to the charge nurse, but the treatment was documented as completed even when it was not. Interviews with staff, including the wound nurse, LPN, DON, and the administrator, confirmed that the facility's staff did not follow physician orders for dressing changes. The staff was expected to inform the next shift if they were unable to complete a treatment, but this protocol was not followed, leading to inaccurate documentation of treatment completion.
Failure to Apply Prescribed Splint for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain mobility. The resident, who has anoxic brain injury, quadriplegia, muscle spasms, and muscle contractures, was observed without the prescribed right-hand wrist splint on multiple occasions. The resident's care plan indicated the need for a right wrist hand splint, and the Treatment Administration Record (TAR) showed an order for the splint to be donned and doffed daily. However, documentation for the application of the splint was incomplete, with a blank entry on one of the observed days. Interviews with facility staff revealed that the Restorative Aide (RA) was primarily responsible for applying the splints but was often unavailable due to being pulled to other duties. It was noted that any nursing staff could apply the splints, but the responsibility was not consistently fulfilled. The Director of Nursing (DON) confirmed that splints should be applied as per physician orders and that documentation should accurately reflect the completion of this task. The lack of documentation and the absence of the splint on the resident indicated a failure to provide the necessary care as outlined in the resident's care plan.
Failure to Maintain Physician Orders for Colostomy Care
Penalty
Summary
The facility failed to ensure that physician orders for colostomy care were maintained and completed as required for a resident with a colostomy. The resident, who had a history of hypertension, cardiac arrhythmia, colostomy status, cerebral infarction, and quadriplegia, did not have active physician orders for routine or as-needed colostomy care. Observations over several days revealed that the resident's colostomy bag was often full and under pressure, indicating a lack of regular care. The resident reported not receiving colostomy care over the weekend and had to request assistance due to concerns about the bag bursting. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that the resident required routine colostomy care, which should be completed by nursing staff on each shift. The staff expected physician orders to specify the frequency of care and changes to the colostomy bag. However, due to a corporate changeover, the facility experienced difficulties in accessing and verifying physician orders, leading to the deficiency in providing necessary colostomy care for the resident.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide appropriate assistive devices to residents who needed them to eat independently. Resident #25, diagnosed with Parkinson's disease and other conditions affecting coordination, had orders for a divided plate and built-up utensils. However, observations showed the resident was often served meals without the necessary built-up utensils, leading to difficulty in eating and food spillage. The resident expressed frustration over not receiving the required adaptive equipment, and staff interviews revealed a lack of awareness about the resident's needs for built-up utensils. Similarly, Resident #110, who had hemiplegia and dysphagia, was supposed to receive meals on a divided plate as per their care plan. Observations indicated that the resident was frequently served meals on regular plates, resulting in food spillage. Interviews with staff, including CNAs and dietary aides, highlighted a lack of knowledge about the resident's need for a divided plate, which was not documented on the dietary ticket. Interviews with various staff members, including CNAs, dietary aides, and the dietary manager, revealed inconsistencies in communication and documentation regarding the provision of adaptive equipment. The dietary manager and other staff members were unaware of the specific needs of the residents, and there was a reliance on dietary tickets that did not accurately reflect the residents' requirements. The Director of Nurses and the Administrator expected that residents would receive adaptive equipment as needed, but the lack of proper documentation and communication led to the deficiency.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify a representative of the State Long-Term Care Ombudsman of resident transfers and discharges. The census was 120. The Ombudsman reported not receiving a monthly transfer report from the facility since April 2024. The Social Services Director (SSD) is responsible for notifying the Ombudsman of resident transfers on a monthly basis, typically by the 5th of each month. However, the SSD was unable to provide documentation of notifications since April 2024 due to a lack of access to her old email following the facility's recent change in ownership. The Administrator confirmed the SSD's responsibility for these notifications and was unaware of the issue. The facility had been experiencing problems with their email system, which resulted in emails not being sent when the system was full, and employees were not notified of this issue. The facility has since implemented a new email system due to the change in ownership.
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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