Windsor Estates Of St Charles
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Charles, Missouri.
- Location
- 2150 West Randolph Street, Saint Charles, Missouri 63301
- CMS Provider Number
- 265518
- Inspections on file
- 40
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Windsor Estates Of St Charles during CMS and state inspections, most recent first.
The facility failed to timely provide final accountings and proper disposition of resident trust funds after death for multiple residents. In several cases, only part of a deceased resident’s trust balance was reported to the state TPL unit, while remaining funds were withdrawn for current or back room and board without written authorization or were left unreported for extended periods. Interest that continued to accrue in deceased residents’ accounts was also held for months without required Personal Funds Account Balance Reports. During interviews, the Administrator and BOM attributed these issues to turnover in the business office, ongoing attempts to "clean up" accounts, uncertainty about handling interest, lack of awareness that transferred funds were personal trust funds, and an incorrect assumption about the allowed timeframe for completing required financial reports and refunds.
A resident who was at risk for falls was not assessed or treated after a reported fall, resulting in a fractured wrist that went unaddressed for two days. Staff failed to follow physician orders for x-ray, immobilization, and RICE treatment, and did not document or provide the prescribed brace or sling. Communication lapses and lack of documentation contributed to the resident experiencing ongoing pain and lack of appropriate care.
A resident with significant mobility limitations and a high fall risk experienced multiple falls from bed due to staff failing to keep the bed in the lowest position and not setting the low air loss mattress to the correct weight. The mattress was repeatedly set too high, and new fall prevention interventions were not consistently implemented or documented after each fall, despite the resident's ongoing incidents and injuries.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, leading to the occurrence and worsening of pressure ulcers.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Multiple residents reported receiving meals that were not hot, and observations confirmed that hot foods and beverages were served below required temperatures due to improper temperature monitoring, lack of insulated covers, and malfunctioning equipment. Staff interviews revealed inconsistent temperature checks and inadequate procedures for maintaining food safety and palatability during meal service.
The facility did not maintain the main parking lot, leaving a large, deep area of damaged asphalt in the visitor parking section. This unrepaired damage affected vehicles traveling through the area, and the Administrator was aware of the issue but had not yet addressed it.
A resident who was dependent on staff for bed mobility and care fell from bed and sustained injuries after a CNA turned away to retrieve supplies, leaving the resident unattended on an unsecured air mattress overlay. The CNA had previously noticed the mattress shifting but did not report it, and the facility lacked a policy for monitoring such overlays. The care plan and therapy evaluation did not clearly specify the number of staff needed for bed mobility, contributing to the incident.
The facility did not ensure the Dietary Manager had completed the necessary training or certification to fulfill the role, and lacked a policy for training or competency requirements. The DM was enrolled in a course but had not finished it, and the required food protection manager certification was not posted, resulting in non-compliance.
Surveyors identified multiple deficiencies in food storage and labeling, including unlabeled and expired food items, lack of discard dates, visible spoilage, and improper refrigerator maintenance such as rust, ice buildup, and missing thermometers. Dietary staff were unclear about cleaning responsibilities, and only food from the dietary department was supposed to be stored in the dining room refrigerator.
Staff failed to consistently provide scheduled ADL care, including showers, nail care, shaving, and grooming, to several dependent residents. Documentation was often incomplete or missing, and residents were observed with poor hygiene, long nails, and unkempt hair. Interviews with residents and family members confirmed that care was not provided as scheduled, and staff gave inconsistent explanations about responsibilities for ADL tasks.
A persistent leak from the water pipe under the dishwasher led to pooled water on the kitchen floor, with staff mopping up the water several times daily. Inspection reports and staff interviews confirmed that the plumbing issue had been ongoing, and the facility was cited for non-compliance with plumbing standards.
The facility failed to provide ordered medications for two residents, leading to deficiencies in care. A resident with a joint prosthesis infection and low back pain did not receive Tramadol for pain management due to delays in prescription and delivery. Another resident with cellulitis and osteomyelitis missed doses of IV antibiotics because the medication was not available upon admission. Staff interviews revealed communication lapses in ensuring medication availability, impacting resident care.
The facility's call system failed to provide audible alerts, requiring staff to rely on visual cues to respond to residents' needs. This deficiency affected all residents, with some experiencing significant delays in assistance. Staff interviews confirmed the absence of pagers or phones to receive alerts, and the administrator was unaware of a state requirement for such devices.
A facility failed to ensure the safety of two residents, leading to serious injuries. One resident, dependent on staff for bed mobility, fell from the bed due to the absence of a required fall mat and lack of reassessment for safety. The resident sustained severe injuries, including intracranial hemorrhage and rib fracture. Another resident, with a rotator cuff tear, was unsafely transferred by staff using a gait belt, causing pain in the injured shoulder. The facility's policies for fall management and safe lifting were not effectively implemented, contributing to these incidents.
A resident with a history of heart failure and muscle weakness was left unattended on a mechanical lift mat in a high bed position, resulting in a fall and a fractured left leg. The resident, who was dependent on staff for transfers, was left alone when a CNA left the room to get a nurse. The incident was witnessed by the resident's roommate, who called for help. The resident was assisted off the floor and diagnosed with a fractured tibia.
The facility failed to implement an admission policy, resulting in a resident's admission without a signed agreement. Additionally, several residents and their representatives did not receive the required 30-day written notice of rate increases, leading to confusion and dissatisfaction. The previous administrator claimed to have mailed the notices, but many residents reported not receiving them.
The facility failed to employ a Food Service Director (FSD) with valid credentials. The FSD, who started in October 2023, did not have a current certification in food safety management. The Administrator had planned to enroll the FSD in a certification course, but this did not occur. The FSD confirmed that he had started but not completed the course, and the Regional Director of Operations acknowledged the lack of certification. A review of the FSD's employee file revealed an expired certification.
A facility failed to ensure a resident with nasal and inhaler medications had a self-administration assessment, physician's order, and care plan. The resident, who was cognitively intact, had medications at their bedside without the required documentation, increasing the potential for medication errors.
A resident with Alzheimer's and repeated falls was found with a swollen, discolored knee, but the injury was not reported to the state agency until six days later, violating the facility's policy requiring immediate notification.
A resident with Alzheimer's and repeated falls was found with a swollen and discolored knee, but the injury was not reported or investigated until several days later, violating the facility's policy on immediate reporting and investigation of injuries of unknown origin.
The facility failed to update the care plan for a resident with wandering behaviors after two incidents where the resident left the skilled nursing unit without staff knowledge or supervision. Despite the resident's Alzheimer's disease and repeated falls, no new interventions were added to the care plan following the incidents.
The facility failed to prevent a resident with Alzheimer's and wandering behaviors from leaving the skilled nursing unit without supervision on two occasions. Staff were unclear about specific interventions, and the doors did not have effective alarms. The DON confirmed the lack of an elopement assessment and root cause analysis.
A facility failed to ensure CNAs changed gloves and performed hand hygiene during catheter care for a resident with neuromuscular dysfunction of the bladder. The CNAs did not adhere to the facility's infection control policies, leading to potential cross-contamination.
Failure to Timely Account for and Properly Disburse Resident Trust Funds After Death
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and disburse resident trust funds and to provide final accountings of resident fund balances within 30 days of a resident’s death, as required. Record review showed that for multiple deceased residents, the facility either did not report the full balance of funds to the Department of Social Services Third Party Liability (TPL) Unit, did not submit Personal Funds Account Balance Reports timely, or withdrew funds for room and board without written authorization or after the resident had expired. For one resident, the ledger showed a trust balance of $8,119.01 at the time of death, but only $3,904.41 was initially reported to TPL, while $3,311.00 was later withdrawn for current and back room and board and an additional $51.60 was withdrawn, leaving $2,311.60 unreported for over 200 days; interest of $2.22 was also held and not reported until more than two months after it was deposited. Another resident’s ledger showed a deposit of $1,073.37 from a previous facility that was documented as personal spending money, but the facility withdrew $690.00 for room and board without authorization and did not use those funds for cremation services or report them to TPL within the required timeframe. Additional record reviews showed similar issues for other deceased residents. One resident had $2,792.85 in the trust account and a subsequent direct deposit of $2,064.00; only $2,618.55 was reported to TPL more than 40 days after death, while $2,058.60 was withdrawn for room and board and not reported. Another resident’s $51.30 trust balance was withdrawn for back room and board and not reported to TPL for over 300 days, and interest of $0.04 remained without a Personal Funds Account Balance Report submitted for more than 300 days after the interest was deposited. A further resident’s $1,295.84 trust balance was not reported to TPL until 81 days after death, and interest of $1.15 was held without a balance report for over 200 days. For another deceased resident, interest of $3.46 continued to be held, and a Personal Funds Account Balance Report was not submitted for more than 200 days after the interest deposit. In an interview, the Administrator and Business Office Manager cited turnover in the Business Office Manager position, the new BOM’s efforts to “catch up” paperwork, uncertainty about how to handle remaining interest, lack of awareness that transferred funds were trust funds, and an incorrect belief that there were 60 days to complete the Personal Funds Balance Report and/or submit refunds.
Failure to Assess and Treat Resident After Fall Resulting in Fracture
Penalty
Summary
Staff failed to assess a resident after a reported fall, did not provide timely treatment, and did not implement or follow physician orders for care following the identification of a fall with injury. The resident, who had diagnoses including heart disease, macular degeneration, muscle weakness, and was at risk for falls, self-reported a fall that occurred two days prior to being evaluated by clinical staff. The fall was not reported by staff at the time it occurred, and no assessment or documentation was completed immediately following the incident. The resident subsequently developed pain, swelling, and bruising to the left arm, which was not addressed until the resident reported these symptoms to a nurse practitioner. Despite clear physician orders to obtain an x-ray, immobilize the arm, and provide RICE (Rest, Ice, Compression, Elevation) treatment, staff did not document or provide these interventions in a timely manner. The x-ray, when eventually performed, revealed an acute distal radial metaphysis fracture. The resident was sent to the emergency room for further evaluation and returned with a splint, but staff continued to fail in documenting assessments, treatments, or the application of the prescribed brace or sling. Interviews with staff and the resident confirmed that the resident was often left without the prescribed immobilization device and continued to experience pain. Multiple staff interviews revealed a lack of communication and failure to follow protocol regarding fall reporting, assessment, and implementation of physician orders. The charge nurse was not informed of the fall, and staff did not provide or document the required treatments. The resident's pain and injury went unaddressed for an extended period, and staff were unaware of the current treatment plan or the location of the prescribed immobilization devices. The facility's own policies required assessment and intervention after any fall, but these were not followed in this case.
Failure to Prevent Falls and Ensure Safe Bed Settings
Penalty
Summary
The facility failed to provide adequate protective oversight and prevent falls for a resident with multiple risk factors, including end stage renal disease, heart failure, muscle weakness, and a right above-the-knee amputation. The resident was assessed as a high fall risk, required extensive assistance with activities of daily living, and was dependent on staff for transfers and mobility. Despite these needs, staff did not consistently ensure that the resident's bed was kept in the lowest position while the resident was in bed, as required by the care plan and facility policy. Additionally, the resident's low air loss mattress was repeatedly set at a weight setting significantly higher than the resident's actual weight, contrary to manufacturer instructions and facility expectations. Observations confirmed that the mattress was set at 340 pounds while the resident weighed 268 pounds, which staff acknowledged could contribute to the resident rolling out of bed. The resident experienced multiple falls from bed, often while reaching for personal items or attempting to reposition, and reported discomfort from frequently sliding down in bed, with feet resting on the footboard. After several falls, there was no documentation that new fall risk interventions were implemented in a timely manner following each incident, as required by the facility's fall policy. Staff interviews revealed inconsistent practices regarding the use of mechanical lift slings, bed positioning, and mattress settings. The resident continued to experience falls, some resulting in skin tears, and staff failed to consistently apply or document new interventions after each event.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages were prepared and served at safe and appetizing temperatures, as required by their own policy. Multiple residents who received meals in their rooms and in the assisted dining room reported that their food was not hot when served. Observations confirmed that during meal service, hot foods such as roast pork, mashed potatoes, and corn were plated, covered with plastic film, and placed on an open metal cart without insulation. The cart also contained beverages, including milk, tea, and juice, which were not kept on ice. The last meal tray was delivered over 30 minutes after plating, and temperature checks of a test tray revealed that hot foods were below the required serving temperatures, and milk was above the safe cold temperature. Interviews with dietary staff and the Dietary Manager revealed that food temperatures were not consistently checked at the steam table, and two wells on the steam table were not functioning to keep food warm. The facility lacked insulated plate covers, and the timing of room tray delivery depended on staff availability. The Dietary Manager and Administrator both acknowledged that food and beverages should be served at proper temperatures, but the observed practices and equipment issues led to food being served at temperatures that did not meet policy or safety standards.
Failure to Maintain Safe and Clean Parking Lot Environment
Penalty
Summary
The facility failed to maintain the main parking lot, resulting in a large area of damaged asphalt at the end of the visitor parking area. Observations revealed that the damaged area was approximately ten feet in diameter and 8-10 inches deep at the center, affecting any vehicle using the area for travel. The Administrator acknowledged awareness of the needed repair and indicated that several projects were in progress, but the area remained unrepaired at the time of the survey.
Resident Fall Due to Unsecured Mattress Overlay and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who required staff assistance for bed mobility and care, fell out of bed while receiving personal care and sustained multiple injuries, including a laceration to the forehead, skin tears, and bruising. The resident was dependent on staff for bed mobility, dressing, and hygiene, and had significant physical limitations due to diagnoses such as respiratory failure, dementia, and stroke. The resident was also on hospice care and used an air mattress overlay on top of a regular mattress, which was reported by staff to shift on the bed. On the day of the incident, a CNA was providing care and rolled the resident onto their side. The CNA then turned away from the resident to retrieve additional supplies from a bedside table, during which time the resident slid off the bed and fell to the floor. The CNA admitted to not having all necessary supplies at the bedside before starting care and did not request additional assistance, despite the mattress overlay shifting and the resident's dependency for mobility. The CNA had previously repositioned the air mattress overlay multiple times during the shift but had not reported the issue to anyone. The facility did not have a policy for monitoring residents using air mattresses or mattress overlays. Interviews with staff and leadership confirmed expectations that supplies should be prepared in advance and that staff should seek help when needed. The physical therapy evaluation did not specify the number of staff required for bed mobility, and the care plan indicated only one staff member was needed for repositioning and turning. The lack of a secure mattress overlay and insufficient supervision during care contributed to the resident's fall and subsequent injuries.
Dietary Manager Lacked Required Competency and Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the appropriate competencies and skill set required to manage the food and nutrition services for all residents. The DM had been in the role since September of the previous year and was enrolled in an online dietary manager course but had not completed it. The DM was unable to specify when the course began or when it would be completed and had not taken any other relevant classes. The DM reviewed some course modules with the Registered Dietician during weekly visits but lacked a completed certification. Additionally, the facility did not have a policy regarding training or competency requirements for the DM position. A review of the Food Establishment Inspection Report from the local county health department indicated that the facility was out of compliance with the requirement for a Certified Food Protection Manager. The required certificate of training was not posted in the food establishment, and the Administrator was unaware of the DM's progress in the course or the expected completion timeline.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
The facility failed to comply with food storage, labeling, and sanitation policies as evidenced by multiple observations in the main dining room and kitchen prep/storage area refrigerators. Surveyors found several food items, such as Jello with fruit, ham sandwiches, potato salad, slaw, thickened lemon water, milk, and cut fruit, that were either not labeled with the date opened, lacked discard dates, or were past their expiration or use-by dates. Some food items showed visible signs of spoilage, such as dried and discolored fruit. Additionally, five pieces of cake in the freezer were not dated, and there was a buildup of food debris in the freezer. Both refrigerators lacked hanging thermometers, and the main dining room refrigerator had rust spots and ice buildup inside. Interviews with dietary staff and the administrator confirmed that only food from the dietary department should be stored in the dining room refrigerator, and that all food should be labeled and discarded according to policy. However, staff were unaware of when the refrigerator was last cleaned or who was responsible for its maintenance. The facility census at the time was 62, and the deficiencies were identified through observation, interview, and record review.
Failure to Provide Scheduled ADL Care and Personal Hygiene Services
Penalty
Summary
Facility staff failed to provide necessary care and services to maintain good personal hygiene and prevent body odor for four residents who were unable to perform their own activities of daily living (ADLs). Multiple instances were documented where residents did not receive scheduled showers, bed baths, nail care, shaving, or haircuts as outlined in their individualized care plans. Documentation was often missing regarding whether care was offered, refused, or provided, and there was a lack of follow-up when residents reportedly refused care. In several cases, there was no resident signature to confirm refusals, and staff did not consistently attempt to reschedule or offer care at a later time. Residents affected by these deficiencies included individuals who were cognitively intact, dependent on staff for bathing and personal hygiene, and in some cases, frequently or always incontinent of urine and/or bowel. Observations revealed that residents had greasy, matted hair, facial hair, long and dirty fingernails, dry and flaky skin, and rooms with noticeable body odor. Interviews with residents confirmed that they had not received showers, shaves, or haircuts for extended periods, despite expressing a desire for such care. Some residents reported that staff told them services like haircuts could not be provided due to regulations, and others stated that staff promised to provide care but did not follow through. Staff interviews revealed inconsistencies in understanding and executing responsibilities for ADL care. CNAs and nurses gave conflicting accounts regarding who was responsible for nail care, shaving, and grooming, particularly for diabetic residents. The facility lacked specific policies for showers, shaving, nail care, or haircuts, and staff assignments for showers and grooming were not always completed as scheduled. Family members and responsible parties also reported concerns about the lack of ADL care, with some having to provide grooming themselves or escalate complaints to facility leadership.
Failure to Maintain Dishwasher Plumbing in Good Repair
Penalty
Summary
The facility failed to maintain the water supply to the dishwasher in good working condition, resulting in a persistent leak from the water pipe under the dishwasher. Observations over multiple days showed water dripping from pipes beneath the dishwashing machine, leading to pooled water under the dishwasher and shelving, which then flowed onto the kitchen floor. The issue was noted during inspections and was observed to have been ongoing for over a year, with kitchen staff mopping up the water several times daily. Inspection reports from the local county public health department documented leaking plumbing and plumbing in disrepair, with the facility being cited for non-compliance. Interviews with staff revealed that while a previous leak under the sink had been repaired, the leak under the dishwasher was considered new by some, though others indicated it had persisted for an extended period. The administrator was not aware of the leak until recently, despite repeated findings by the health department during follow-up visits, where the leak remained uncorrected.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure that ordered medications were available for administration to two residents, leading to deficiencies in care. Resident #1 was admitted with a diagnosis of infection of a joint prosthesis and low back pain, with an order for Tramadol to manage pain. However, the medication was not available upon admission, and the resident experienced pain without relief. Despite attempts to contact the physician and pharmacy, the medication was not delivered promptly, resulting in the resident being administered Tylenol instead. The resident's family member expressed concerns about the lack of pain management, and the resident was eventually transferred to another facility. Resident #2 was admitted with cellulitis, diabetes with a foot wound, and osteomyelitis, requiring IV antibiotics. The facility did not have the necessary medication upon the resident's arrival, as the hospital did not send the medication orders in advance. The resident missed several doses of the prescribed IV antibiotic, Cefazolin, due to the delay in medication delivery. The facility's cubex contained the medication, but it was not utilized, leading to a lapse in the resident's treatment. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of communication and coordination in ensuring medications were available and administered as ordered. The pharmacy consultant confirmed delays in receiving prescriptions and medication deliveries. The deficiencies highlight the facility's failure to adhere to professional standards of practice in medication management, impacting the residents' care and well-being.
Deficient Call System Lacks Audible Alerts
Penalty
Summary
The facility failed to maintain an effective call system that adequately alerted staff when residents required assistance. Observations and interviews revealed that the call system did not produce an audible sound to notify staff of activated call lights. Instead, staff had to rely on visual cues, such as a monitor at the nurses' station or a light above the resident's door, to know when a call light was on. This deficiency affected the entire facility, which had a census of 66 residents across three halls. Interviews with staff, including CNAs and an LPN, confirmed that they did not carry pagers or phones to receive alerts, and the system's lack of an audible function meant that staff could miss calls for assistance, especially if they were not near the monitors or the resident's room. Several residents reported significant delays in response times when they activated their call lights. One resident mentioned waiting over 30 minutes for assistance and having to resort to yelling for help. Another resident noted that staff often walked past their room without acknowledging the activated call light. The facility's administrator acknowledged the absence of an audible alert in the call system and was unaware of a state agency exception that required staff to carry pagers. The corporate office was reportedly working with the state agency on updates to the call light system, but the reason for the lack of an audible function remained unclear.
Failure to Ensure Resident Safety and Proper Transfer Techniques
Penalty
Summary
The facility failed to ensure the safety of a resident who was dependent on staff for bed mobility. During care, the resident was rolled to their side, reached out to the opposite side, and fell from the bed to the floor. The care plan required a fall mat to be in place, but it was not present at the time of the fall. The resident, who often reached out during care, had not been reassessed for safety with bed mobility. As a result of the fall, the resident required hospitalization and sustained serious injuries, including intracranial hemorrhage, epidural hematoma, subdural hematoma, concussion, and a right rib fracture. Another resident, who required staff assistance for transfers, was unsafely transferred by two staff members using a gait belt. The resident, who had a rotator cuff tear, reported pain in the injured shoulder during the transfer. The facility's policy for safe lifting and movement of residents was not adhered to, as staff did not use the appropriate techniques or equipment for the transfer. The resident's care plan indicated a need for two-person assistance, but the staff failed to follow the correct procedures, leading to the resident experiencing pain and discomfort. The facility's policies for fall management and safe lifting were not effectively implemented or followed. Staff did not communicate the resident's resistive behavior during care, which could have prompted a reassessment for safety. Additionally, the facility did not ensure that the necessary equipment, such as fall mats and mechanical lifts, was used as required by the care plans. These failures contributed to the incidents involving both residents, resulting in injuries and hospitalizations.
Resident Left Unattended on Bed Results in Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was dependent on staff for transfers and at risk for falls. The resident was left unattended on a mechanical lift mat with the bed in a high position, leading to the resident sliding off the bed and sustaining a fracture of the left leg. This incident occurred when a staff member left the room to get a nurse after noticing the resident had scratched their back and was bleeding. The resident involved had a history of heart failure, stage 5 chronic kidney disease, a below-the-knee amputation of the right leg, and muscle weakness. The resident was assessed as being at risk for falls due to deconditioning and was dependent on staff for bed mobility, transfers, and wheelchair mobility. The resident was alert, oriented, and able to make needs known, as documented in their care plan and Minimum Data Set (MDS). The incident was reported to the administrator, and it was noted that the resident had been left on the side of the bed while the staff member left the room. The resident's roommate witnessed the fall and called for help. The resident was subsequently assisted off the floor by staff and sent to the emergency room, where a fractured left tibia was diagnosed.
Deficiency in Admission Policy and Rate Increase Notification
Penalty
Summary
The facility failed to develop and implement an admission policy and protocol, resulting in a deficiency related to the admission agreement for a resident. The resident, who was cognitively impaired and admitted for rehabilitation, did not have an admission agreement signed by their representative. The representative, who held power of attorney, reported not receiving any admission packet or signing any paperwork upon the resident's admission. Additionally, the representative was informed verbally by the previous administrator about an immediate payment requirement and a future rate increase, but did not receive any written documentation. The facility also failed to provide at least a 30-day written notice of rate increases to several residents and their representatives. Multiple residents and their representatives reported not receiving any notification of rate increases, despite the facility's policy requiring such notice. In some cases, residents were cognitively intact and responsible for their own financial matters, yet they were unaware of the rate changes until they received a bill reflecting the increase. The facility's business office manager was on vacation when the rate increase letters were supposedly sent, and the previous administrator claimed to have mailed the letters, but several residents and their representatives did not receive them. The facility's documentation showed inconsistencies in the communication of rate increases, with some letters lacking addresses and others not being sent at all. The corporate office had approved the rate increase, and the previous administrator signed a memo acknowledging the implementation of the increase. However, the lack of proper notification to residents and their representatives led to confusion and dissatisfaction among those affected. The facility's failure to adhere to its own policies and ensure proper communication contributed to the deficiency identified by the surveyors.
FSD Lacks Valid Certification
Penalty
Summary
The facility failed to employ a Food Service Director (FSD) with valid credentials, as required by their job description. The Director of Nursing (DON) confirmed that the FSD, who started in October 2023, did not have a current certification in food safety management. The Administrator had planned to enroll the FSD in a certification course, but this did not occur. The FSD himself confirmed that he had started but not completed the certification course. The Regional Director of Operations (RDO) also acknowledged that the FSD lacked the necessary certification. A review of the FSD's employee file revealed that his previous certification had expired. This deficiency had the potential to affect all 55 residents in the facility, although there were no residents receiving enteral feeding at the time of the survey.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident with nasal and inhaler medications at their bedside had a self-administration of medication assessment, a physician's order, and a care plan completed. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had Astepro nasal solution, Albuterol sulfate HFA inhalation aerosol solution, and Trilogy inhaler at their bedside. However, there was no evidence of a self-administration assessment, physician's order, or care plan for these medications in the resident's electronic medical record (EMR). During an interview, the resident confirmed using the medications as needed. The facility's policy requires an interdisciplinary team (IDT) assessment and a physician's order for self-administration of medications, but these steps were not documented. The Director of Nursing (DON) acknowledged the oversight and removed the medications until an assessment could be completed. This failure to follow protocol increases the potential for medication errors for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident (R21) to the State of Missouri Department of Health and Senior Services in a timely manner. R21, who had diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls, was found to have a swollen and discolored left knee on 03/12/24. Despite the observation and subsequent X-ray order by RN3, the incident was not reported to the Administrator or Director of Nursing (DON) until 03/18/24, when the DON learned of the fracture and reported it to the state agency the same day. The facility's policy mandates that such injuries be reported within two hours of discovery, which was not adhered to in this case. The deficiency was identified during a review of R21's records and interviews with the staff involved. RN3 noted the injury but failed to report it to the appropriate authorities, and the DON only became aware of the situation six days later. This delay in reporting violated the facility's abuse prevention and prohibition policy, which requires immediate notification to the state agency and law enforcement. The failure to report the injury promptly was confirmed by the DON during the interview, acknowledging that the injury should have been reported on the day it was discovered.
Failure to Immediately Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an investigation was immediately initiated when an allegation of injury of unknown origin was found for a resident. The resident, who had diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls, was found to have a swollen and discolored left knee on 03/12/24. Despite the observation and documentation by a Registered Nurse (RN), the injury was not reported to the Administrator or Director of Nursing (DON) until 03/18/24, when the resident was found to have a fracture. The facility's policy requires that injuries of unknown origin be reported immediately and an investigation initiated, which did not occur in this case. The DON confirmed that she first learned of the injury on 03/18/24 and initiated an investigation on the same day. The delay in reporting and investigating the injury of unknown origin was a clear violation of the facility's abuse prevention and prohibition policy. The policy mandates that nursing staff report such injuries immediately to the Administrator and that an investigation be conducted promptly. The failure to follow these procedures resulted in a significant delay in addressing the resident's injury and ensuring their safety.
Failure to Update Care Plan for Wandering Resident
Penalty
Summary
The facility failed to update the care plan for a resident with wandering behaviors after two incidents where the resident left the skilled nursing unit without staff knowledge or supervision. The resident, diagnosed with Alzheimer's disease, cerebral infarction, and repeated falls, was found in the independent living Bistro and later in the chapel, both times without any changes made to the care plan. The care plan, dated several months prior, only included general interventions such as offering pleasant diversions and redirection, with no updates following the incidents. The Director of Nursing confirmed that there was no incident report for the first incident and acknowledged that the facility did not have a policy related to updating care plans. Despite the resident's wandering behaviors and the incidents, the care plan remained unchanged, and no new interventions were put in place to address the resident's safety and wandering tendencies. The lack of updates to the care plan and the absence of a policy for such updates contributed to the deficiency identified in the report.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a resident with wandering behaviors from leaving the skilled nursing unit without staff's knowledge or supervision. The resident, identified as R21, left the skilled nursing unit and was found in the independent living Bistro and later in the chapel, which was located past two closed double doors at the end of the hall. The resident had a history of Alzheimer's disease, cerebral infarction, and repeated falls, and was known to wander. Despite this, the care plan did not have updated interventions after the incidents, and staff were unsure of the specific interventions in place to supervise the resident. On two separate occasions, R21 was able to leave the skilled nursing unit without staff noticing. On the first occasion, the resident was found in the Bistro, and on the second occasion, the resident was missing for over two hours before being found in the chapel. Interviews with staff revealed that they were aware of the resident's wandering behavior but were unclear about the specific interventions to prevent it. The doors leading to the chapel did not have an effective alarm system, and there was no documentation of hourly monitoring after the resident was found. The Director of Nursing (DON) confirmed that there was no elopement assessment for R21 prior to the incidents and no root cause analysis or investigation into how the resident exited the unit. Additionally, there was no documentation of the 15-minute checks that were supposed to be implemented after the second incident. The facility's policy on elopements stated that all residents should be afforded adequate supervision and assessed for behaviors that put them at risk for elopement, but this was not followed in R21's case.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) changed gloves and performed hand hygiene when transitioning from a contaminated area to a clean area during catheter care for a resident. The facility's policy on Standard Precautions and Prevention of Catheter-Associated Urinary Tract Infections mandates that hand hygiene be performed immediately after any manipulation of or contact with the catheter site, catheter, tubing, drainage bag, or emptying container, even when gloves are worn. Additionally, gloves should be removed before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated. However, during an observation, CNA2 and CNA1 did not adhere to these protocols while providing catheter care to a resident diagnosed with neuromuscular dysfunction of the bladder, who had a recent urinalysis showing mixed pathogen growth. CNA2 and CNA1 failed to change gloves and perform hand hygiene at multiple points during the procedure, including after handling soiled linens and before touching clean items and areas of the resident's body. During the catheter care, CNA2 used the same gloves to remove bowel movement, handle soiled linens, and then touch clean items such as a new incontinence brief and a clean shirt. CNA1 also failed to change gloves after handling soiled linens and before assisting with clean tasks. Furthermore, CNA2 did not perform hand hygiene after removing gloves at the end of the procedure. Interviews with CNA2 and the Director of Nursing (DON) confirmed that gloves should be changed when moving from dirty to clean areas, indicating a clear deviation from the facility's established infection control policies.
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The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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