North Village Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Moberly, Missouri.
- Location
- 2041 Silva Lane, Moberly, Missouri 65270
- CMS Provider Number
- 265330
- Inspections on file
- 50
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 60 (3 serious)
Citation history
Health deficiencies cited at North Village Park during CMS and state inspections, most recent first.
Two residents with psychiatric and behavioral diagnoses, sharing a room, became involved in a conflict over a vape pen that escalated at the bedroom door when one resident pinned the other against the wall and punched the resident multiple times in the head and face. Staff responding to a call for help found both residents behind the door, with the aggressor still able to strike the victim as they were being separated. The victim, who reported not hitting back, sustained a knocked-out tooth, a loose tooth, a chipped tooth, a lip laceration, and multiple red, swollen areas on the head, later requiring dental evaluation and treatment recommendations for root canal, crown, or extraction of two lower anterior teeth. Facility documentation, including nursing notes, resident statements, and a psychosocial post-incident questionnaire, identified one resident as the aggressor and confirmed that the incident met the facility’s own definition of abuse, demonstrating a failure to ensure a resident was free from abuse by another resident.
A resident with paranoid schizophrenia and generalized anxiety disorder, assessed as low elopement risk and independent in mobility, eloped through a service hall exit door after a floor tech exited through that door without a spotter and left the alarm off. The service hall was accessible from a common area used by residents, and video showed the resident first unsuccessfully attempting to open the door, then returning later and exiting when the unalarmed door opened. The resident walked around the building, crossed a four-lane highway, and sat near dumpsters behind a coffee shop, while staff—including an LPN and CNA—remained unaware the resident had left until notified by local police, despite documentation indicating the resident was in the building during that period.
A resident with a history of severe methamphetamine use disorder, antisocial personality disorder, major depressive disorder, prior incarceration, and multiple suicide attempts reported seeing a housekeeper smoking meth in a shower room and later requested meth from that staff member. Over roughly two weeks, the housekeeper allegedly delivered several small baggies of meth to the resident’s room, despite facility policies prohibiting abuse and any illegal drug use, possession, or distribution on the premises. The resident later tested positive for meth on a pre‑operative UDS, leading to cancellation of a planned surgery, and paraphernalia and baggies were found in the resident’s room. The housekeeper denied providing drugs but admitted to recent meth use and refused drug testing, and the facility substantiated that staff provision of illegal substances to the resident constituted abuse.
A resident with schizophrenia, mood disorders, cognitive impairment, and a history of agitation and assaultive behavior experienced multiple behavioral emergencies, including physical aggression toward staff, attempts to elope, and self-harm resulting in lacerations requiring sutures. Despite a PASRR identifying significant behavioral health needs and the facility’s policies requiring person-centered assessment, IDT review, and root cause analysis after behavioral crises, the facility did not document an IDT meeting to analyze underlying causes or to develop and revise individualized interventions. Care plan problems related to aggression and self-inflicted injury were marked as resolved shortly after incidents and before the resident’s return from psychiatric hospitalization, and new elopement behaviors and frequent Code Greens were not translated into specific, updated care plan interventions. Staff and other residents reported fear of the resident’s erratic outbursts, staff relied informally on smoking to calm the resident even though it was not listed as a coping skill, and the facility failed to consistently notify the physician of ongoing behavioral emergencies as required by policy.
A resident’s guardian notified facility leadership by email that the resident would not be returning and requested follow-up regarding the resident’s trust account funds. Facility records showed the resident had a remaining trust balance, but there was no documentation that these funds were returned to the resident or responsible party within the required timeframe. The Business Office Manager/Resident Trust Clerk reported being unaware of the resident’s discharge, and the Social Services Director stated she had only just located the guardian’s email, resulting in the facility’s failure to issue the required refund check and accounting as outlined in its own policy.
A resident with a history of mental illness, poor impulse control, and a court-appointed guardian was subjected to sexual abuse by a CNA who violated facility policies prohibiting staff–resident relationships and defining sexual abuse, including via technology. The CNA entered a personal phone number into the resident’s cell phone, exchanged sexually explicit texts and a photo in underwear, and engaged in physical sexual contact with the resident in the resident’s room, a linen closet, and a smoking area. The resident later became behaviorally escalated and disclosed to staff that a staff member had sent pictures, then told the Activity Director about the sexualized texting and physical contact and showed the messages and videos, leading to a facility investigation that concluded the CNA’s actions constituted abuse.
A resident prescribed lithium for bipolar disorder did not receive required laboratory monitoring as ordered by providers, with no documentation of lab draws, refusals, or physician notification when labs were missed. The resident, who had multiple psychiatric diagnoses and was cognitively intact, became increasingly lethargic and was ultimately found unresponsive with signs of lithium toxicity, requiring hospitalization, intubation, and dialysis. Staff interviews revealed ongoing issues with lab order processing and lack of oversight, contributing to the failure to detect and address the resident's deteriorating condition.
Surveyors found extensive environmental and maintenance deficiencies, including unaddressed holes in walls, missing or broken fixtures, mold-like growth, water damage, and persistent cleanliness issues in resident rooms, restrooms, and common areas. Residents reported unresolved maintenance requests and inadequate housekeeping, with some having to clean up after others. Staff interviews revealed inconsistencies in the work order process and incomplete daily rounds, contributing to ongoing deficiencies.
Staff failed to follow professional standards for food storage, preparation, and hygiene, resulting in unlabeled and undated food items, improper hand and glove hygiene, inadequate use of hair restraints, and unsanitary kitchen conditions. A resident reported finding a hair in their soup, and observations revealed buildup of grease and debris on equipment, missing or damaged fixtures, and lack of an air gap at the ice machine drain. Maintenance and dietary staff were unaware of some requirements, and cleaning responsibilities were inconsistently executed.
Staff failed to follow infection control protocols during blood glucose monitoring, including improper hand hygiene, inadequate disinfection of glucometers, and placing devices on unprotected surfaces. The facility did not retest water or document corrective actions after high Legionella levels were found, nor did it test residents with pneumonia for Legionella. Enhanced Barrier Precautions were not used during care for residents with indwelling devices, and catheter bags and tubing were left on the floor. These deficiencies were observed across several residents and care situations.
The facility did not reimburse checking account fees deducted from the resident trust account and failed to provide reasonable access to personal funds for residents. Multiple residents and staff confirmed that access to funds was limited to a short window during weekdays, and monthly reconciliations showed unreimbursed deductions for operating expenses from resident accounts.
The facility did not follow physician orders or professional standards for several residents, including failing to obtain and document required bloodwork, not performing or recording vital sign checks before administering medication, and documenting administration of nutritional supplements that were not actually provided. Staff interviews and record reviews revealed ongoing issues with communication, documentation, and adherence to orders.
Multiple residents reported that their meals, including hot foods like eggs and chicken, were consistently served cold, and observations confirmed that both hot and cold food items were not maintained at safe temperatures during meal service. Staff did not consistently follow procedures to keep hot foods above 135°F and cold foods below 41°F, resulting in unappetizing and improperly handled meals for residents.
Several residents with physician-ordered mechanical soft diets were served regular texture foods or inappropriate menu items, such as whole chicken, bacon, and cucumber salad, instead of ground or chopped alternatives. Errors were linked to outdated meal cards, staff unfamiliarity with dietary requirements, and inconsistent communication between nursing and dietary staff. Residents with chewing and swallowing difficulties did not consistently receive food in the prescribed form.
The facility did not consistently provide substantial or routine snacks to residents between meals, with reports and observations indicating that snacks were limited to chips, snack cakes, and crackers, and were only available upon request. Some residents, including those with special dietary needs, did not receive appropriate snacks, and staff did not routinely offer snacks to all residents as required by facility policy and professional standards.
Multiple residents reported ongoing mouse infestations in their rooms and common areas, with observations confirming mouse droppings, holes in walls, and evidence of nesting. Bait stations were often empty or missing, and maintenance staff only checked them sporadically. The pest control vendor was not notified of the rodent problem inside the building and only provided exterior rodent control, resulting in ineffective pest management throughout the facility.
Two residents with significant weight loss did not receive proper weight monitoring, timely notification to clinical staff, or consistent provision of ordered nutritional supplements. Staff failed to update care plans or implement interventions as required by facility policy, and communication lapses led to missed dietary orders and unaddressed resident requests for increased food portions.
A resident with a history of choking and aspiration risk, who required a mechanical soft diet, was mistakenly served a regular pork loin meal instead of the intended pimento cheese sandwich substitution. Due to this error, the resident choked, became unresponsive, and later died from food aspiration and respiratory failure. Staff interviews confirmed that the correct diet was not served due to miscommunication and failure to verify the tray against physician orders.
Two residents with complex psychiatric histories were involved in a physical altercation, during which one resident pushed and kicked another, causing a nondisplaced spiral fracture of the upper arm. Staff were unaware of escalating issues between the residents prior to the incident, and the injured resident required emergency medical evaluation and treatment.
A resident was involved in a physical altercation resulting in a right humeral fracture that required surgical evaluation. Facility staff did not notify the resident's legal guardian about the altercation, the ambulance transfer to the hospital, the diagnosis, or the planned surgery, despite facility policy requiring such notifications. Both the guardian and the on-call emergency contact reported not receiving any communication from staff regarding these significant events.
A resident with a history of behavioral and cognitive challenges was physically assaulted by another resident who accused them of theft. Despite an LPN's attempt to intervene, the aggressor pulled the victim to the ground by the hair and struck them, resulting in a head hematoma, black eye, hip bruise, and rib pain. Staff and resident statements confirmed the sequence of events and the injuries sustained.
A resident with a history of behavioral and cognitive challenges was physically assaulted by another resident during a dispute over money, resulting in a head injury and bruising. Despite staff witnessing the incident and the resident being sent to the ER, facility administrators did not report the abuse to the state agency or law enforcement, as required by policy.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive appropriate treatment and services, as the care plan lacked individualized interventions and documentation to address their specific needs.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that care and services provided met professional standards of quality, as observed through practices that did not align with established guidelines.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services tailored to their needs, resulting in a deficiency related to inadequate mental health and trauma-informed care.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, and sexual abuse, physical punishment, and neglect by any individual.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors. Staff did not take sufficient steps to monitor or protect residents from environmental risks.
The facility failed to provide enough staff with the required competencies and skills to meet the behavioral health needs of residents, resulting in unmet care requirements.
A resident with a history of mental illness was subjected to verbal, mental, and physical abuse by a staff member during a behavioral emergency, including being forcefully grabbed, shoved against a wall, and threatened with profane language. Multiple staff witnessed and reported the abusive actions, which escalated the situation instead of de-escalating it, in violation of facility policy and crisis intervention training.
A facility failed to conduct a comprehensive investigation into an allegation of staff-to-resident abuse during a behavioral emergency. Despite reports from two staff members and incomplete video footage showing aggressive restraint and verbal abuse by an HR Manager, the facility did not obtain statements from all witnesses or review all available evidence before concluding the investigation.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident with a history of elopement and significant psychiatric diagnoses was allowed unsupervised access to an exterior courtyard, and staff failed to ensure the door was latched upon the resident's return. The resident exited through the unlatched door, climbed onto the roof using a punching bag base, and left the premises undetected. Required hourly face checks were not completed or documented, and staff were unclear about monitoring responsibilities, resulting in the resident being missing for over 12 hours before being found.
The facility failed to provide palatable and properly heated food to residents, as hot meals were consistently served cold due to the discontinuation of steam tables and reliance on insulated carts. Multiple residents and staff reported ongoing complaints about food temperature, and direct observations confirmed that hot foods were served well below required temperatures. Staff delays, frequent cart openings, and lack of reheating options contributed to the deficiency.
Two residents in a facility were subjected to physical abuse by other residents due to staff's failure to report concerning behaviors and intervene promptly. In one case, a resident was assaulted after derogatory comments were ignored by an aide. In another, a resident admitted to hitting another but was not immediately separated, leading to a second assault.
The facility failed to administer medications as ordered for several residents, including a diabetic resident who missed doses of insulin and Ozempic, a resident with chronic pain who did not receive lidocaine patches, and another resident who did not receive prescribed hydrocodone-acetaminophen after an ER visit. Staff did not follow policies for notifying physicians or using backup pharmacies, leading to deficiencies in care.
A resident experienced urinary urgency and dysuria, but the facility failed to assess or treat the symptoms for seven days, leading to hospitalization for acute pyelonephritis. Upon readmission, staff did not administer the prescribed antibiotic doses, and there was a lack of communication with the physician. Interviews revealed that staff did not follow facility policies for notifying changes in condition and adhering to physician orders.
A resident with depression and mobility issues was involved in an incident where an LPN prevented them from taking a cup from the dining room to their room, leading to a confrontation. The resident attempted to retrieve the cup, resulting in the drink mix spilling on both the resident and the LPN. Witnesses described the LPN as disrespectful, and the resident was upset by the incident. The facility's policy on dignity and respect was not adhered to, resulting in a deficiency.
A resident with a history of suicidal ideation obtained a razor from another resident and self-harmed, highlighting the facility's failure to provide protective oversight. The resident's care plan documented their need for secure oversight due to impulsive behavior and poor judgment. The facility lacked a specific policy for managing razors, leading to the incident.
A resident with a history of behavioral issues physically assaulted another resident, resulting in a neck contusion. The assigned CNA failed to intervene during the altercation, citing inadequate training on handling aggression. The facility's policies on abuse prevention were not effectively implemented, leading to the incident.
A resident with bipolar disorder and schizophrenia in a secured unit did not receive prescribed medications, including Wellbutrin XL and Abilify, due to insurance and availability issues. The facility staff failed to ensure timely administration, leading to the resident's agitation and aggressive behavior. Interviews revealed inadequate communication and documentation by staff regarding medication unavailability.
The facility failed to provide adequate food service by not ensuring proper portion sizes and alternative options for residents with regular diet orders. Residents reported being left hungry due to insufficient portions and a lack of variety in meals and snacks. Dietary staff were not consistently using portion control utensils, and there was a lack of alternative vegetables when residents disliked the ones served. Management was unaware of these issues, indicating a communication gap.
The facility failed to serve food at safe and appetizing temperatures, with several residents expressing dissatisfaction with the taste and temperature of their meals. Observations showed food served below the required temperatures, and interviews revealed inconsistencies in expected serving temperatures among dietary staff.
A resident with mental health issues gave $40.00 to a Hall Monitor through a cash app transaction for a THC vape pen, but did not receive the item or get their money back. The facility's investigation confirmed the misappropriation of funds by the staff member, violating the facility's policy on abuse and neglect.
A facility failed to provide adequate supervision for a resident with behavioral difficulties, leading to an elopement incident. The resident, with a history of mental illness and self-harm, used a chair to climb over a fence and leave the facility during an unattended smoke break. Additionally, the facility did not consistently implement fall prevention interventions for another resident with a history of falls, resulting in multiple incidents without updates to the care plan.
The facility failed to provide sufficient staff with the necessary skills to meet the behavioral health needs of residents on locked units. Staff from non-nursing departments were frequently pulled to provide 1:1 monitoring, leading to limited access to recreational areas and increased resident frustration. The facility's staffing plan was inadequate, and staff were often uninformed about the reasons for monitoring, compromising resident safety and well-being.
The facility failed to involve two residents and their representatives in care plan meetings, despite their cognitive ability and expressed desire for family involvement. The facility's policy lacked clarity on meeting frequency, leading to missed meetings and inadequate documentation. Staff interviews revealed systemic issues, including part-time MDS Coordinator prioritizing assessments over meetings and inconsistent notification by the Social Service Director.
A resident underwent a left breast needle biopsy, but the facility failed to report the results indicating breast cancer to the physician for eight months. The facility also did not ensure the resident attended a follow-up appointment with the oncologist. The resident's care plan indicated impaired thought processes, and the facility lacked a procedure for following up on biopsy results, leading to delays in diagnosis and treatment.
The facility failed to ensure that three residents with mental disorders received individualized treatment and services to meet their needs. These residents displayed verbal and physical behaviors on multiple occasions, and the facility did not adequately develop and implement meaningful interventions, including non-pharmacological interventions and alternate strategies. The facility also failed to ensure that the residents received timely and appropriate treatment or services to address their psychosocial well-being.
Resident-to-resident altercation resulting in dental and head injuries
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse during a resident-to-resident altercation in a shared bedroom. Two residents with significant psychiatric and behavioral diagnoses were roommates and became involved in a conflict related to a vape pen. One resident, who was cognitively intact with diagnoses including schizophrenia, anxiety disorder, and paranoid schizophrenia, reported becoming angry after an interaction at the bedroom door and admitted to striking the roommate several times in the mouth and head. The other resident, who had a guardian and diagnoses including bipolar disorder, autistic disorder, ADHD, impulse disorder, and oppositional defiant disorder, reported attempting to talk calmly with the roommate and then being pinned against the door and punched in the head and face. According to nursing progress notes and staff interviews, floor staff heard a shuffling sound and a call for staff around 12:20 A.M. and, upon entering the room, observed both residents behind the door with the aggressor pinning the other resident against the wall in the corner. As staff intervened to separate them, the aggressor reached over a staff member and struck the victim again. The aggressor later stated that the conflict began when the roommate had possession of the vape pen and that he/she became angry when the roommate allegedly hit him/her with the door or in the shoulder while he/she was trying to leave the room. The victim consistently reported that he/she did not hit or kick back at the roommate and that the roommate pinned him/her and began punching him/her in the head and face. The victim sustained multiple documented injuries as a result of the altercation. Nursing notes described one lower front tooth broken out, another tooth loose, and a third tooth chipped, along with a small laceration inside the lower lip where the tooth was missing. Multiple red areas were noted on the sides and top of the head, including a darker, slightly swollen area at the left front hairline. The resident complained of head pain rated five out of ten and later required evaluation for unresolved dental pain, with a dental consultation recommending root canal and crown or extraction of two lower anterior broken teeth. The facility’s own abuse and neglect policy defined abuse to include resident-to-resident altercations and required that residents who allegedly mistreat another resident be removed from contact with the resident during the investigation, underscoring that the incident met the facility’s definition of abuse when one resident willfully struck another, causing physical harm and pain. The facility’s investigation and documentation identified the aggressor as the resident who pinned the roommate and delivered multiple punches to the head and face, and the victim as the resident who sustained dental and head injuries. The psychosocial post-incident questionnaire completed for the aggressor recorded that the resident was the aggressor in the incident and acknowledged that he/she should not have hit the peer and should have left the vape pen in the smoke box. Staff accounts, resident statements, and clinical documentation collectively show that the altercation escalated from a disagreement over a vape pen and a conflict at the bedroom door, culminating in physical abuse that resulted in significant injury to the victim, thereby demonstrating the facility’s failure to ensure the resident was free from abuse as required by its policy and regulatory standards.
Resident Elopement Through Unalarmed Service Hall Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secure exit and adequate supervision, resulting in a resident eloping through a service hall exit door without staff knowledge. A floor technician (Floor Tech A) used the service hall exit door, which was equipped with a keypad lock and a separate keyed alarm, and exited the building without ensuring that a second staff member (a spotter) was present to monitor the door while it was unalarmed. Video footage reviewed by the Assistant Administrator showed that at 11:32 A.M. Floor Tech A turned the keyed alarm off, entered the keypad code, opened the door, and exited the facility. No staff member remained at the door to monitor it, and Floor Tech A did not re-enter through that door, leaving the door unalarmed and unsecured. The resident involved, identified as Resident #5, had diagnoses including paranoid schizophrenia, chronic pain, and generalized anxiety disorder. The resident’s elopement risk assessment, completed shortly after admission, indicated no prior history of elopement or attempts, no expressed desire to go home, no packing of belongings, no exit-seeking behavior, and no wandering, and the resident was assessed as low risk for elopement. The care plan documented that the resident was at risk for moving around, nervousness, pacing, and restlessness related to anxiety, and directed staff to offer activities and provide protective oversight with supervision for ADLs. The quarterly MDS showed the resident was cognitively intact, did not wander, had no functional limitations in movement, and was independent in ambulation and mobility. On the day of the incident, the service hall was accessible to residents from a common area called the Hangout, which residents used for activities and meals and which opened to the service hall containing vending machines and access to locked resident units. After Floor Tech A exited and left the service hall exit door unalarmed, video footage showed that at 11:35 A.M. the resident entered the service hall from the Hangout and attempted to open the service hall exit door by pushing down the handle, but the door did not open and the resident walked away. At 11:50 A.M., the resident returned, pushed the door handle again, and this time the door opened without triggering an alarm, allowing the resident to exit to the back of the facility. The resident then walked around the building, proceeded approximately two blocks, crossed a four-lane highway, and sat in the grass near dumpsters behind a local coffee shop. Staff, including the charge LPN and the CNA assigned to the resident’s hall, were unaware that the resident had left the building until the local police department notified the Administrator that the resident was at the coffee shop. Staff documentation of hourly face checks recorded the resident as being in the building shortly before and after the time the resident was seen on video exiting through the service hall door, and no staff reported observing the resident leave the facility.
Staff Provision of Methamphetamine to Resident with Substance Use Disorder History
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to maintain an illegal drug‑free environment when a housekeeper provided methamphetamine to a resident on multiple occasions. The resident had a documented history of severe methamphetamine use disorder, antisocial personality disorder, major depressive disorder, prior incarceration, homelessness, multiple suicide attempts, and recent methamphetamine intoxication with psychiatric hospitalization. The resident’s care plan identified stimulant dependence, substance abuse, paranoia/suspiciousness, suicidal ideation and attempts, and a history of possession charges and incarceration, with planned interventions including monitoring for cravings and relapse warning signs, encouraging participation in recovery programs, teaching coping skills, and assessing the resident for safety. Facility policies on Abuse and Neglect, Illegal Drug Use, and Code of Conduct clearly prohibited abuse, illegal drug use, possession, or distribution on the premises and required staff to refrain from illegal conduct. According to interviews and record review, the resident reported that three to four weeks before the incident he/she entered a resident shower/bathroom and observed Housekeeper N smoking methamphetamine from a glass pipe. The resident stated that seeing the staff member using methamphetamine triggered a desire to use again. Approximately one week later, the resident approached Housekeeper N and asked for methamphetamine. The resident reported that over a two‑week period, Housekeeper N brought him/her methamphetamine in three to four small plastic bags, delivered to the resident’s room on multiple occasions, and that the last time he/she received methamphetamine from this staff member was on a Sunday identified as 02/08/26. The resident acknowledged having paraphernalia in his/her room, including a straw and clear bags, and voluntarily disclosed their location to facility administration and law enforcement. On the date of a scheduled surgery, the resident underwent a urine drug screen at a pre‑operative appointment and tested positive for methamphetamine, resulting in the cancellation of the surgery. Progress notes documented that upon return to the facility the resident was very tearful, and the facility was notified that the positive test was for methamphetamine. The resident’s emergency contact reported to Social Services that the resident had told him/her a facility employee, identified as Housekeeper N, had provided methamphetamine, and during a visit the resident pointed out this staff member as the source of the drugs. In the facility’s investigation, the resident gave a statement that only this staff member had provided methamphetamine four to five times over a two‑week period, while Housekeeper N denied giving drugs but admitted to recent methamphetamine use and refused drug testing. Baggies and paraphernalia were found in the resident’s room, and the facility concluded that staff providing a resident with illegal substances constituted abuse, substantiating that abuse occurred.
Failure to Perform Root Cause Analysis and Person-Centered Behavioral Care Planning After Repeated Behavioral Emergencies
Penalty
Summary
The deficiency involves the facility’s failure to provide thorough, person-centered behavioral health assessment and care planning for a resident with serious mental illness and a history of behavioral issues, including wandering and assaultive behavior. The resident’s PASRR documented schizophrenia, psychosis, major depressive and mood disorders, substantial cognitive impairment, poor judgment and insight, wandering without knowing where he or she was, agitation, assaultive behaviors, and a need for a secured behavioral unit and structured environment. The PASRR also identified needs for psychiatric follow-up, behavioral monitoring, and interventions to change inappropriate behavior. Despite this, the resident’s care plan listed only general behavioral problems such as verbal aggression, agitation, mood swings, anxiety, and aggression, with broad non-pharmacological interventions and triggers, and did not incorporate all PASRR information or clearly defined, individualized coping strategies. Smoking, which staff later used as a primary de-escalation tool, was not listed as a coping skill. On one date, the resident exhibited escalating behavior, yelling and using profane language toward staff, threatening another resident, and ultimately throwing a wet floor sign that struck a staff member in the face, causing injury and requiring EMS and police involvement. A behavioral emergency (Code Green) was called, and the resident was transported to a psychiatric hospital. Facility documentation, including the Registered Nurse Investigation and care plan entries, noted that an IDT meeting was “in progress” and referenced review of the PASRR and physician notification, but there was no documented interdisciplinary team meeting that analyzed the underlying causes of the behavior or revised the care plan with new, individualized interventions. The care plan problems related to physical aggression and staff injury were marked as “resolved” on the same day they were initiated and before the resident returned from the hospital, and the plan of care section that was supposed to list new interventions did not contain specific, updated approaches. After the resident’s return, the facility failed to recognize and address new elopement-related behaviors through assessment and care plan revision. Shortly after being assessed as having no history of elopement, the resident left the secured unit, rapidly wheeled to the front entrance, and then into a family room where he or she broke a glass window with a hand in an attempt to leave the facility, sustaining lacerations that required 20 sutures and emergency room treatment. Staff interviews described the resident yelling about wanting to leave, bursting out of the secured unit when the door opened, and multiple staff being afraid of the resident. There was no documentation of an IDT meeting to determine root causes of this new elopement behavior or to develop person-centered interventions, and the care plan problem for the self-inflicted injury from breaking the window was also marked as resolved before the resident returned from a subsequent psychiatric hospitalization. Following the resident’s second return from psychiatric hospitalization, the resident continued to have frequent behavioral emergencies, including verbal aggression, self-harm behavior involving reopening sutured wounds, and repeated attempts to leave the facility, resulting in five Code Greens over a 10‑day period. Observations showed the resident leaving the secured unit without staff, going to the front entrance, yelling and demanding to leave, and requiring behavioral emergency responses. Staff reported that the only effective redirection was allowing the resident to smoke, yet smoking was not incorporated into the care plan as a coping skill. The facility did not consistently notify the physician of these ongoing behaviors as required by policy, and the care plan revision dated after another front-door incident documented a new problem of unprovoked verbal aggression and attempts to leave but left the interventions section blank. Residents and staff reported being fearful of the resident’s erratic outbursts, and the record showed no documented root cause analysis or comprehensive, person-centered behavioral care planning to address the resident’s changing behavioral health and elopement-related needs. The facility’s own policies on Behavioral Health Services, Behavioral Emergency, and Intensive Monitoring required person-centered assessment and care planning, IDT involvement, root cause analysis, close monitoring for residents with behavioral crises, and physician/psychiatrist notification after behavioral emergencies. Despite these policies, the record for this resident lacked evidence of thorough review of behavioral health emergencies, lacked documented IDT analysis of underlying causes, and failed to update and individualize the care plan with effective interventions in response to repeated behavioral crises, new elopement behavior, and ongoing aggression and distress.
Failure to Timely Return Discharged Resident’s Trust Funds
Penalty
Summary
The facility failed to return a discharged resident's trust funds in accordance with its policy and regulatory requirements. The facility's Resident Trust policy, revised on 9/21/25, required that upon discharge, the facility provide an up-to-date accounting of the resident's trust account and issue a check for all remaining personal funds within five days, along with a complete accounting record. Email correspondence from the resident's guardian to the Social Services Director and the Administrator, dated 11/25/25, formally notified the facility that the resident would not be returning and requested a call back to discuss the remaining trust account funds. A Trust Transaction History report dated 11/24/25 showed the resident had a trust fund balance of $103.99. Record review showed no documentation that the facility returned the resident's funds to the resident or responsible party within 30 days of discharge. During interviews, the Business Office Manager/Resident Trust Clerk stated she was in charge of the resident trust account but was unaware the resident had discharged. The Social Services Director reported she had just found the email from the guardian indicating the resident would not return. The Administrator stated his expectation was that remaining resident trust funds were to be sent to the resident or family within five days of discharge, but this did not occur for this resident.
Failure to Protect a Resident From Sexual Abuse by a CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by a staff member, specifically a CNA, in violation of the facility’s abuse, neglect, and employee–resident relationship policies. The resident involved had a documented history of mental illness, including anxiety, depression, mood changes, manic episodes, poor impulse control, poor decision making, poor social boundaries, and a history of failed residential placements and short-term employments. The resident had a legal guardian and had been identified in the PASARR Level II evaluation as needing a structured environment, psychotherapy, drug therapy and monitoring, structured socialization activities, development of appropriate support networks, and implementation of plans to change inappropriate behavior. The resident’s care plan documented poor impulse control and various behavioral issues, including manic episodes, false allegations, and fixation when things did not go his/her way. Despite these known vulnerabilities and the facility’s written policies prohibiting employee dating relationships with residents and defining sexual abuse (including via technology), the CNA engaged in an inappropriate, sexualized relationship with the resident. According to the resident’s statement and the facility’s investigation, the resident asked the CNA for his/her phone number, and the CNA entered the number into the resident’s phone. They then began texting and exchanging videos. Text messages from the CNA to the resident included explicit sexual content, such as a message describing giving hand jobs and a sexually suggestive statement about making the resident’s genitals hard, accompanied by a photo of the CNA in underwear. The resident reported that this communication progressed to physical contact, including kissing and mutual genital touching. The resident stated that the sexual contact occurred in the resident’s room, in a linen closet, and in the area where cigarettes were located. The resident described that the CNA waited until other residents went outside for a smoke break before approaching him/her, and that on at least one occasion another resident knocked on the door, the CNA left to assist that resident, and then returned to continue the sexual contact. The facility’s investigation concluded that the CNA crossed professional boundaries by sharing a personal phone number, texting, sending videos, and engaging in physical contact with the resident, and that these actions were not allowed under facility policy and constituted abuse. The resident’s guardian reported that the resident did not have the ability to consent to sexual activity and had been determined incapacitated and disabled by a court, with poor impulse control and decision making. On the day the incident came to light, nursing notes documented that the resident had been flipping tables and chairs, was vaping in the common area, and expressed dissatisfaction with medications and daily routine. Later that same day, the resident told staff that a staff member of the opposite gender had sent pictures to his/her phone. The Activity Director, responding to a behavioral code, calmed the resident and brought him/her to the office, where the resident disclosed being upset about texting and video communication with the CNA and being told to erase the messages. The resident then showed the Activity Director the texts and videos on the phone. These events and findings formed the basis for the determination that the facility failed to ensure the resident was free from sexual abuse by a staff member.
Failure to Obtain and Document Ordered Lithium Monitoring Labs Resulting in Resident Harm
Penalty
Summary
Facility staff failed to obtain and document required laboratory monitoring for a resident prescribed lithium for bipolar disorder, as ordered by the psychiatric Nurse Practitioner. Despite multiple physician orders for lithium levels, complete blood counts (CBC), and comprehensive metabolic panels (CMP) over several months, there was no evidence in the medical record that these labs were drawn, attempted, or refused by the resident. Additionally, there was no documentation that the resident’s physician was notified when the ordered lab work was not obtained. The resident’s care plan also lacked specific interventions for monitoring lithium side effects, signs of toxicity, or lab monitoring, despite the known risks associated with lithium therapy. The resident, who had diagnoses including bipolar disorder, depression, PTSD, and mild intellectual disabilities, was cognitively intact and had a history of stable lithium dosing. In the weeks leading up to the incident, staff and aides observed the resident becoming increasingly groggy, sleeping more, and being unsteady, but these changes were attributed to medication adjustments rather than potential toxicity. The resident continued to receive scheduled lithium doses as documented in the Medication Administration Record, with no indication of medication refusal. On the day of the incident, the resident was found unresponsive, with vomiting, incontinence, pale and yellow skin, and low oxygen saturation. Emergency services were called, and the resident was transferred to the hospital. At the hospital, the resident was found to have a critically high lithium level, acute kidney failure, elevated BUN and creatinine, and required intubation and multiple rounds of dialysis. Interviews with facility staff and providers revealed ongoing issues with lab orders not being scheduled or completed, confusion over the electronic medical record system, and a lack of oversight after the departure of the Resident Care Coordinator who previously audited lab completion. The psychiatric Nurse Practitioner and physician both confirmed that labs were ordered and expected to be drawn, and that failure to obtain these labs delayed detection and intervention for lithium toxicity.
Widespread Environmental and Maintenance Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a safe, clean, comfortable, and homelike environment for residents. Observations revealed widespread issues throughout resident rooms, restrooms, common areas, and shower rooms, including heavy dust and debris on exhaust fans, holes in walls, missing or broken fixtures such as light covers, soap and paper towel dispensers, towel bars, and window blinds. Numerous rooms had evidence of water damage, black mold-like areas on ceilings and walls, peeling paint, and discolored or missing floor tiles. Several plumbing fixtures, such as toilets and faucets, were loose, leaking, or not functioning properly, and some heating/ventilation units lacked covers or had broken vent covers. Residents reported that some of these issues, such as missing paper towel holders, broken soap dispensers, and malfunctioning lights, had persisted for extended periods despite being reported to staff. Interviews with residents indicated dissatisfaction with the facility's response to maintenance concerns, with some residents stating they had reported issues multiple times without resolution. In several cases, residents described having to clean up after other residents due to inadequate housekeeping, such as cleaning fecal matter or urine themselves. Observations also noted strong odors of urine and stale smells in some rooms, sticky floors, and visible stains on bedding and furniture. In common areas, such as dining and shower rooms, surveyors found dried food spills, fecal matter, rust stains, and chipped paint, further indicating lapses in cleanliness and maintenance. Facility staff interviews revealed that while a work order system was in place for reporting and addressing maintenance issues, there were inconsistencies in how and where work orders were submitted and collected. Maintenance staff reported that repairs were typically completed within a week of receiving a work order, but daily rounds by department heads to identify issues were not always completed due to emergencies or staffing shortages. Housekeeping staff stated that rooms were cleaned daily, but nursing staff were also expected to address cleanliness between housekeeping visits. Despite these processes, the observations and resident interviews demonstrated ongoing and unresolved deficiencies in the facility's environment.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Observations revealed multiple instances of improper food storage, including unlabeled and undated containers of food in both the kitchen and satellite snack rooms, as well as unsealed bags of dry goods exposed to air. Food items were found uncovered, and refrigerators and storage areas contained scattered debris and expired or unidentifiable food items. The Dietary Manager confirmed that staff did not consistently clean or discard expired items and that expectations for labeling, dating, and sealing food were not met. Hand and glove hygiene practices were not followed by dietary staff. Staff were observed preparing food without washing hands between tasks, touching unsanitary surfaces such as their face and hair restraints, and then handling food or clean dishes without proper handwashing. Gloves were used incorrectly, with staff donning gloves without prior handwashing and using the same gloves for multiple tasks. The handwashing sink in the kitchen was missing faucet handles, making it difficult to use properly, and staff were seen turning off the faucet with clean hands, further compromising hygiene. Personal beverages were consumed in food preparation areas, and hair restraints did not fully contain staff hair, as evidenced by a resident finding a hair in their soup. The physical environment of the kitchen and food storage areas was not maintained in a sanitary condition. There was a buildup of grease and debris on cooking equipment, range hood baffle filters, and various surfaces throughout the kitchen. Walls, floors, and ceilings were dirty, damaged, or in disrepair, with missing tiles, flaking paint, and accumulation of dust and debris. The range hood filters had not been regularly cleaned, and the ice machine drain lacked an air gap, creating a risk of backflow. Maintenance and dietary staff were unaware of some of these requirements, and cleaning responsibilities were not clearly defined or consistently executed.
Multiple Failures in Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to current infection prevention and control standards in multiple areas, as observed through staff actions and record reviews. Staff did not consistently follow proper hand hygiene protocols before and after glove use, particularly during blood glucose monitoring procedures. In several instances, staff used alcohol wipes instead of EPA-registered disinfectant wipes to clean glucometers, did not disinfect devices according to manufacturer instructions, and placed glucometers directly on surfaces without barriers. Additionally, staff failed to remove soiled gloves and perform hand hygiene after procedures involving blood, and did not always discard blood-filled test strips immediately after use. The facility did not implement or follow a comprehensive water management program to control Legionella risk. Despite receiving laboratory results indicating high levels of Legionella pneumophila in multiple water samples, the facility did not retest water samples as required, nor did it document corrective actions or maintain records of flushing and descaling faucets, monitoring chlorine levels, or inspecting backflow prevention devices. Residents diagnosed with pneumonia were not tested for Legionella, contrary to facility policy and CDC recommendations. Maintenance staff lacked training and documentation for water testing and were not fully integrated into the infection control committee or water management processes. Infection control practices for Enhanced Barrier Precautions (EBP) were not followed for residents with indwelling devices such as urinary catheters. Staff did not wear required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for these residents. Catheter bags and tubing were observed lying directly on the floor, and staff were unaware of the need for EBP in these situations despite prior education. Additionally, oxygen tubing was not properly stored when not in use for one resident. These failures were observed across multiple residents and care situations, indicating systemic lapses in infection prevention and control.
Failure to Reimburse Resident Trust Account Fees and Provide Reasonable Access to Funds
Penalty
Summary
The facility failed to ensure that checking account fees deducted from the resident trust account were reimbursed by the facility, affecting 127 residents whose funds were managed by the facility. Monthly reconciliations showed repeated deductions for deposit slip and check orders, but there was no documentation that these amounts were reimbursed to the resident trust account. Interviews with the Business Office Manager (BOM) and Corporate Business Office Manager revealed that the responsibility for reimbursement was not fulfilled due to staff turnover, lack of oversight, and issues with new software implementation. The administrator confirmed that operating expenses such as deposit slips and check orders should not be charged to the resident trust fund. Additionally, the facility failed to provide residents with reasonable access to their personal funds. Residents could only access their funds between 10:30 A.M. and 2:00 P.M., Monday through Friday, and only if they made their request during a narrow window when CNAs circulated a list of residents with trust account balances. If a resident missed this window, they could not access their funds until the next business day. This process was confirmed by interviews with cognitively intact residents, CNAs, and the BOM, all of whom described the limited and inflexible access to personal funds. Facility policies and resident agreements indicated that residents should have access to their funds during regular business hours, but did not specify such restrictive hours or exclude Saturday availability. The lack of timely reimbursement for account fees and the restricted access to personal funds were not in accordance with facility policy or regulatory expectations, as confirmed by staff and resident interviews and review of facility documentation.
Failure to Follow Physician Orders and Professional Standards of Practice
Penalty
Summary
The facility failed to follow professional standards of practice for seven residents by not adhering to physician orders and not ensuring required services were provided as ordered. For five residents, staff did not obtain or document ordered bloodwork, including therapeutic medication level monitoring and other diagnostic tests. There was also no documentation that physicians were notified when bloodwork was not obtained or was uncollected, despite repeated orders for labs such as Depakote levels, ammonia levels, CBCs, and other critical tests. Interviews with staff and review of records revealed ongoing issues with lab orders not being scheduled or completed, and a lack of follow-up or communication with providers regarding missed labs. One resident with hypertension and diabetes did not have blood pressure or pulse checks documented prior to administration of antihypertensive medication, despite specific parameters in the physician's order. Additionally, blood sugar checks (Accu Checks) were not consistently performed or documented as ordered, and staff were unclear about the requirements for monitoring and documentation. Interviews with the resident and staff confirmed that blood pressure and blood sugar checks were not being performed as required, and documentation practices were inconsistent or incomplete. Another resident with orders for a nutritional supplement (Magic Cup) did not receive the supplement as ordered, and staff documented administration even when the supplement was not available. Observations and interviews with dietary and nursing staff revealed confusion about responsibilities for providing and documenting supplements, and the supplement had not been available for some time. The resident reported not receiving the supplement, and staff confirmed that documentation was based on assumption rather than direct observation or confirmation of administration.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items to residents at safe and appetizing temperatures, as required by their own policy and food safety standards. Multiple residents reported that their meals, particularly breakfast eggs and other hot foods, were consistently served cold. Observations confirmed that hot food items such as smothered chicken, stuffing, green beans, and soup were served at temperatures significantly below the required minimum of 135 degrees Fahrenheit, with recorded temperatures ranging from approximately 103 to 117 degrees Fahrenheit. Cold food items, such as ice cream, were also not maintained at appropriate temperatures, resulting in melted ice cream being served to residents. During meal service, dietary staff prepared and plated food, covering plates and placing them into insulated tray carts for delivery to various dining areas. However, the process did not maintain the required food temperatures, as evidenced by test trays measured after service, which consistently showed food items below the acceptable temperature range. Additionally, cold items like egg salad sandwiches were not consistently stored on ice, and cold salads were served at temperatures above the recommended maximum of 41 degrees Fahrenheit. Staff interviews confirmed awareness of the required temperature standards, but the observed practices did not align with these expectations. The deficiency affected a large number of residents, including those on regular and mechanical soft diets. Residents expressed dissatisfaction with the temperature of their meals, and observations showed that improper handling and storage of both hot and cold foods during meal preparation and service contributed to the failure to meet food safety and quality standards. The facility's failure to adhere to its own policies and regulatory requirements for food temperature resulted in residents receiving meals that were neither safe nor appetizing.
Failure to Serve Food According to Physician-Ordered Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for several residents with physician-ordered mechanical soft diets. Multiple observations revealed that staff did not serve food items according to the prescribed menu or diet orders. For example, one resident with an order for a mechanical soft diet was repeatedly served regular texture foods, such as a sausage patty cut into pieces instead of ground sausage with gravy, regular smothered chicken instead of ground chicken, and bacon instead of the prescribed ground sausage. The resident, who wore only top dentures due to ill-fitting bottom dentures, reported difficulty chewing and a preference for soft foods. Additionally, the resident's meal card was outdated and did not reflect the current diet order, leading to further errors in meal preparation and service. Other residents with mechanical soft diet orders were also served inappropriate food items. Two residents were observed receiving cucumber and tomato salad, which was firm and crunchy, instead of the required chopped steamed vegetables. The dietary aide responsible for serving these meals was new and unfamiliar with the specific dietary requirements for each resident, contributing to the errors. Meal tickets for these residents correctly indicated the need for a mechanical soft diet, but the wrong food items were still served. Another resident with a history of esophageal dilation and no teeth, who required a mechanical soft diet with no bread, was served sandwiches on white bread and whole fried chicken breasts, both of which were not suitable for their dietary needs. The resident reported choking on these foods and stated that white bread would get stuck in their throat. Interviews with dietary and nursing staff revealed inconsistencies in the process for updating and using meal tickets, with some staff using outdated cards and others not discarding previous versions. Facility leadership, including the DON, Registered Dietitian, and Administrator, all stated that staff were expected to follow current diet orders and use up-to-date meal cards, but this was not consistently practiced.
Failure to Provide Substantial and Routine Snacks Between Meals
Penalty
Summary
The facility failed to provide nourishing and substantial snacks to residents when substantial meals were scheduled 14 hours apart. Multiple residents reported during a group interview that snacks were not routinely offered, were not substantial, and often consisted only of chips, snack cakes, cookies, or crackers, with no sandwiches, fruits, or drinks available. Some residents stated that snacks were only available if specifically requested, and that the snack room was not monitored, leading to some residents taking more than their share and others not receiving any. One resident noted that diabetic-appropriate snacks or snacks containing protein were never provided. Observations confirmed that snacks were kept in locked nourishment kitchens and were not passed individually to residents; only chips, cheese puffs, and Chex mix were available, with no drinks, sandwiches, or other substantial food items present. Interviews with staff revealed that snacks were delivered with the supper cart and typically included chips, snack cakes, and occasionally bananas or sandwiches, though sandwiches were rarely provided. Staff did not routinely pass snacks to all residents, instead only providing them upon request due to the nourishment kitchen being locked. The dietary manager and DON both stated that bedtime snacks should be passed to all residents and should be of substantial nutritive value and variety, while the registered dietitian specified that snacks should contain protein, carbohydrate, and fat, such as milk, a sandwich, or fruit. Despite these expectations, the facility's practice did not align with policy or professional standards, resulting in residents not consistently receiving appropriate snacks.
Failure to Implement Effective Pest Control Measures for Mice
Penalty
Summary
The facility failed to implement effective pest control measures to eliminate mice from multiple areas, including resident rooms, the dry food storage room, and nourishment kitchens. Numerous residents reported frequent sightings of mice in their rooms, with some stating that mice ran across their beds, lived behind air conditioning units, and left droppings on personal items and bedding. Observations confirmed the presence of mouse droppings, holes in walls near HVAC units, and shredded materials believed to be used by mice for nesting. In some cases, residents resorted to personal methods, such as using snake cage shavings, to deter mice due to the ongoing problem. Interviews with residents consistently revealed that mice were a persistent issue throughout the facility, with reports of mice running in hallways, being found in beds, and even being seen in common areas such as the shower room and nourishment kitchens. Observations in the dry storage room and nourishment kitchen revealed mouse droppings, gnawed containers, and a dead mouse under food storage shelves. Some bait stations were found to be empty or missing bait, and in at least one instance, a resident requested a bait station due to the presence of mice in their room. Interviews with maintenance staff and the pest control vendor indicated that the facility's pest control program was not effectively addressing the rodent problem inside the building. Maintenance staff reported checking traps and bait stations only weekly or when time allowed, and the pest control vendor confirmed that their services were limited to treating for roaches inside and only checking exterior rodent bait stations. The vendor was not informed of the rodent problem inside the facility and did not provide rodent control services in resident areas, despite being aware of resident complaints.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to follow its own weight monitoring policy and did not ensure proper nutritional interventions for two residents experiencing significant weight loss. For one resident with diagnoses including COPD, vitamin deficiency, GERD, hyperlipidemia, and schizophrenia, there was a documented weight loss exceeding 5% in one month and over 10% in six months. Despite this, there was no evidence that the physician, Registered Dietitian, or Dietary Manager were notified as required by policy. Additionally, staff did not monitor the resident's weight weekly, and the care plan was not updated to address the ongoing weight loss. The resident reported requesting double portions for several months without success, and interviews revealed that staff were unaware of these requests and did not implement additional interventions. Another resident with dementia and psychotic disorder, who required assistance with eating, also experienced significant weight loss—over 14% in six months. Physician orders for nutritional supplements such as Magic Cup and health shakes were not consistently documented or provided. Observations showed that the resident was not served the ordered supplements during meals, and staff interviews confirmed a lack of awareness and communication regarding supplement orders. The dietary and nursing staff did not coordinate to ensure the supplements were administered, and the care plan did not reflect the physician's orders or address the resident's weight loss. In both cases, there was a lack of weekly weight monitoring, failure to notify appropriate clinical staff of significant weight changes, and inadequate documentation and implementation of nutritional interventions. The deficiencies were confirmed through record reviews, staff and resident interviews, and direct observation, all indicating that the facility did not adhere to its policies for monitoring and addressing weight loss in residents.
Failure to Follow Physician Diet Orders Results in Fatal Choking Incident
Penalty
Summary
A resident with a history of choking and aspiration risk, who was on an assist to dine program and had physician orders for a mechanical soft diet, was served a regular diet tray containing pork loin. The dietary staff had determined that the pork loin was not suitable for mechanical soft diets and had substituted pimento cheese sandwiches for residents requiring this diet. However, due to a miscommunication and error during meal service, the resident received the regular pork loin tray instead of the intended mechanical soft substitution. The resident began choking while eating the meal and became unresponsive, ceasing to breathe. Staff initiated the Heimlich maneuver and CPR, and emergency services were called. Despite these efforts, the resident was transported to the hospital and later expired. The cause of death was determined to be food aspiration leading to respiratory failure and hypoxia. Interviews with staff revealed that the error occurred when the dietary staff and LPN misidentified the correct tray for the resident, resulting in the resident being served food inconsistent with the prescribed mechanical soft diet. Facility policies required that all residents be provided with the prescribed diet as ordered by the physician, and that staff verify the correct tray and diet before serving. In this incident, these procedures were not followed, as the resident's tray was not properly checked against the diet order, and the substitution intended for mechanical soft diets was not provided. The failure to follow physician orders and facility policy directly led to the resident receiving an inappropriate meal, resulting in a fatal choking incident.
Removal Plan
- Education on diet policy, supervision of dining rooms, and preparation of therapeutic diets.
- The facility uses pictures of all three meals showing therapeutic diet consistencies which are sent to and approved by the dietary manager prior to serving any meals.
- Dietary staff send a menu to all units showing alternatives for all regular and mechanically altered diets.
- All food substitutions are approved by the dietary manager.
- The facility holds daily briefings regarding diets/meals between the dietary manager and charge nurse/Director of Nursing (DON).
- Menus are sent to all units and posted on each unit, followed by documented communication from charge nurse/DON to floor staff of any changes.
- The facility reviews all resident diagnoses, diet orders, and aspiration risk.
Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident physically assaulted them, resulting in significant injury. Specifically, one resident pushed another to the ground and kicked them in the head while they were down. This altercation led to the injured resident being sent to the emergency room, where they were diagnosed with a nondisplaced spiral fracture of the right humerus. The incident was witnessed by staff, who responded after hearing a commotion and observing the assault in progress. The resident who was assaulted had a complex medical and psychiatric history, including schizophrenia, PTSD, autistic disorder, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, and ADHD. Their care plan indicated a need for 24-hour supervision due to the severity of their behaviors and mental illness symptoms, as well as a history of aggression and anxiety. The resident was known to require assistance with activities of daily living and was at risk for aggressive outbursts and anxiety-related behaviors. The resident who committed the assault also had a history of psychiatric diagnoses, including schizophrenia, bipolar disorder, schizoaffective disorder, and impulse control disorder. Their records documented recent aggressive and threatening behaviors, including physical aggression towards staff and others, poor impulse control, and a history of violence. At the time of the incident, staff were not aware of any issues between the two residents until after the altercation occurred. The facility's failure to prevent this altercation resulted in a serious injury to one resident.
Failure to Notify Guardian of Resident Injury and Hospitalization
Penalty
Summary
The facility failed to notify a resident's legal guardian regarding the extent of injuries and subsequent medical interventions following a physical altercation with another resident. After the incident, the resident was found on the floor with visible injuries, including red marks on the forehead and right elbow, and reported significant pain and inability to bend the right elbow. The resident was transferred by ambulance to a hospital for evaluation, where a nondisplaced spiral fracture of the right humerus was diagnosed, and surgical repair was recommended. Although a staff member stated that a voicemail was left for the guardian about the altercation and transfer, the guardian and the on-call emergency contact both reported not receiving any notification or voicemail regarding the incident, the transfer, or the diagnosis. Facility policy requires prompt notification of the resident's representative in the event of significant changes, such as accidents resulting in injury, transfers, or the need for surgical intervention. Record review showed no evidence that the guardian was informed about the transfer, the results of the hospital evaluation, or the need for surgery. Interviews confirmed that the guardian expected immediate notification of such events and would have contacted the resident if informed. The administrator also confirmed that staff are expected to follow the notification policy, which was not adhered to in this case.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident. The incident began when one resident accused another of stealing $3.00 and attempted to search the accused resident's pockets. Despite the presence of an LPN who intervened and stood between the two residents, the aggressor reached around the staff member, grabbed the other resident by the hair, and pulled them to the ground. The aggressor then struck the resident in the side while the staff member attempted to shield the victim from further harm. Multiple staff and resident statements confirmed the sequence of events, including the use of racial slurs and physical aggression. The resident who was attacked sustained significant injuries, including a large hematoma on the left temple, a black eye, a bruise on the right hip, and rib pain. The resident reported severe headaches and pain, with a pain score of 7 out of 10. Medical evaluation in the emergency room confirmed an acute hematoma on the left temporal scalp. Observations following the incident documented visible bruising and discoloration on the resident's forehead, eye, and hip, as well as ongoing rib soreness. The resident who was attacked had a history of behavioral challenges, including diagnoses such as watershed brain damage, bipolar disorder, anxiety, impulse control disorder, major depressive disorder, ADHD, oppositional defiant disorder, and borderline intellectual functioning. At the time of the incident, the resident was cognitively intact, had moderate symptoms of depression, and required staff supervision for activities of daily living. The altercation was witnessed by staff, and statements from both the aggressor and the victim corroborated the physical nature of the abuse and the events leading up to it.
Failure to Report Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to report an incident of physical abuse involving two residents to the state agency and law enforcement, as required by its own Abuse and Neglect Policy. The incident occurred when one resident accused another of stealing money, leading to a verbal altercation that escalated into physical violence. Despite staff intervention, the aggressor grabbed the other resident by the hair, pulled them to the ground, and struck them in the side, resulting in visible injuries including a large hematoma on the head and bruising on the hip. The injured resident was subsequently sent to the emergency room for evaluation and treatment of a closed head injury. The resident who was assaulted had a complex medical and psychiatric history, including watershed brain damage, bipolar disorder, anxiety, impulse control disorder, and borderline intellectual functioning. At the time of the incident, the resident was cognitively intact but required supervision for activities of daily living and had a history of behavioral challenges. Documentation and interviews confirmed the sequence of events, the injuries sustained, and the involvement of staff who witnessed and attempted to intervene in the altercation. Despite clear evidence of physical abuse resulting in injury, the facility's administrative staff, including the Assistant Administrator and Administrator, chose not to report the incident to the state agency or law enforcement. They determined that the event did not constitute abuse, despite the facility's policy requiring immediate reporting of all alleged violations involving abuse, especially those resulting in serious bodily injury. This failure to report was confirmed through interviews with administrative staff, who acknowledged their decision not to notify authorities.
Failure to Provide Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified based on the lack of evidence that the resident received necessary care and interventions tailored to their mental health and psychosocial needs, as required by regulatory standards. Surveyors observed that the resident's care plan did not address their specific mental health diagnosis or trauma history, and there was no documentation of individualized interventions or services to support their psychosocial adjustment. This omission resulted in the resident not receiving the comprehensive care needed for their condition.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff, or detailed events leading to the deficiency. No additional information regarding specific patient conditions, medical history, or the exact nature of the services in question is provided in the report.
Failure to Provide Appropriate Mental Health and Trauma-Informed Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified when the resident did not receive the necessary care and interventions tailored to their mental health and psychosocial needs, as required by their condition and history. This lack of appropriate services was observed and documented by surveyors during the review.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Insufficient Competent Staff for Behavioral Health Needs
Penalty
Summary
The facility did not ensure that there were enough staff members with the necessary competencies and skills to meet the behavioral health needs of residents. This deficiency was identified based on observations and findings that staff were not adequately equipped to address or manage the behavioral health requirements of the resident population. The lack of sufficient and appropriately skilled staff directly impacted the facility's ability to provide care tailored to the behavioral health needs of its residents.
Failure to Protect Resident from Staff Abuse During Behavioral Emergency
Penalty
Summary
A deficiency occurred when a facility failed to protect a resident from verbal, mental, and physical abuse by a staff member, specifically the Human Resource Manager (HR). The incident involved the HR Manager cursing, taunting, threatening, and physically grabbing the resident by the shirt and forcefully placing them into a chair. The HR Manager also aggressively shoved the resident against the wall during a behavioral emergency response. Multiple staff interviews corroborated that the HR Manager used profane language, yelled at the resident, and made threatening statements, including saying he would slam the resident's head through the wall and that he did not care if he lost his job. The HR Manager's actions escalated the situation, and several staff described the behavior as abusive and inappropriate for crisis intervention. The resident involved had a documented history of mental illness, including bipolar disorder, anxiety, impulse control disorder, and other psychiatric diagnoses. The resident was cognitively intact, able to communicate needs, and had a history of behavioral issues such as aggression and spitting when agitated. On the day of the incident, the resident became upset during a smoke break, leading to a behavioral emergency. The HR Manager's response included physical restraint and verbal threats, which were not in accordance with the facility's policies on abuse prevention or nonviolent crisis intervention training. The facility's policy clearly defines abuse to include the willful infliction of injury, intimidation, and the use of threatening or demeaning language, all of which were observed or reported in this incident. Video footage from the facility's cameras, as well as multiple staff interviews, confirmed that the HR Manager used excessive force and inappropriate language during the incident. Staff reported that the HR Manager's demeanor and actions prolonged and escalated the behavioral emergency, rather than de-escalating it as required by training. The administrator did not review the camera footage and relied on the resident's denial of abuse and the HR Manager's denial, despite multiple staff reports and direct observations of abusive behavior. The failure to protect the resident from abuse constituted a violation of the facility's own policies and federal regulations regarding resident rights and safety.
Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident abuse during a behavioral emergency involving a cognitively intact resident. Two staff members reported that the Human Resource (HR) Manager was abusive toward the resident during the incident, which occurred in the facility's smoke room. The facility's policy requires a comprehensive investigation, including obtaining statements from all involved staff and reviewing all pertinent information, but these steps were not fully completed. Video footage from the smoke room was provided but was incomplete, with several minutes missing at critical points during the incident. The footage that was available showed the HR Manager physically restraining the resident in an aggressive manner and staff restraining the resident in a chair. Despite the presence of multiple staff members during the incident, the facility did not obtain written statements from all witnesses, specifically failing to collect statements from a Certified Medication Technician and a Nurse Aide who were present. Interviews with these staff members later revealed that they witnessed and described aggressive and abusive behavior by the HR Manager, including physical restraint, yelling, cursing, and threatening gestures toward the resident. However, these accounts were not included in the facility's investigation, as the staff were not asked to provide statements. The administrator also did not review the available camera footage and based the conclusion of the investigation on limited information, ultimately deciding to unsubstantiated the abuse claim.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Protective Oversight and Supervision for Elopement Risk Resident
Penalty
Summary
A facility failed to provide protective oversight and a safe environment for a resident who was assessed as an elopement risk, had a history of previous elopement, and resided on a secured behavioral unit. Staff allowed the resident into an exterior courtyard unsupervised and did not ensure the door was securely latched when the resident returned inside. The resident subsequently exited through the unlatched door, climbed onto the roof using a punching bag base, and left the premises without staff knowledge. Video footage confirmed the resident was unsupervised in the courtyard and used objects in the environment to facilitate elopement. Staff failed to complete required hourly face checks on the resident from 7:30 P.M. until approximately 11:30 P.M., as mandated by facility policy for residents at risk of elopement. Documentation of these checks was missing, and staff interviews revealed confusion and lack of awareness regarding responsibility for monitoring the resident. The charge nurse was not informed of the resident's change in behavior or the incident in the courtyard, and staff did not recognize or respond to the resident's increased agitation and delusional state earlier in the evening. The resident was missing for over 12 hours before being located by staff. The resident had a complex psychiatric history, including diagnoses of PTSD, antisocial personality disorder, bipolar disorder with psychotic features, schizoaffective disorder, and a history of substance abuse. The resident had demonstrated treatment non-adherence, delusional thinking, and a desire to leave the facility, all of which were documented in the medical record and care plan. Despite these known risks, the facility did not implement or follow adequate supervision and monitoring protocols, resulting in the resident's elopement.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained at a safe and appetizing temperature, as required by facility policy. The policy specified that hot foods such as cereal, meat, entrees, potatoes, pasta, soup, and vegetables should be served at temperatures greater than 135 degrees Fahrenheit, preferably between 160 and 175 degrees Fahrenheit. However, observations and interviews revealed that the facility had discontinued the use of steam tables and steam carts due to budget cuts, resulting in hot foods being served cold or at room temperature. Meals were plated in the kitchen and transported to the units on insulated carts, but the carts were often opened and closed multiple times, and food was left on the carts for extended periods before being served. Multiple residents reported that their hot food was consistently served cold, and staff confirmed that the steam carts had been removed, leading to numerous complaints. During meal service observations, hot foods such as sausage, waffles, and oatmeal were found to be significantly below the required serving temperatures, with sausage at 85 degrees Fahrenheit, waffles at 78 degrees Fahrenheit, and oatmeal at 120 degrees Fahrenheit. Additionally, oatmeal was transported on top of the cart with only plastic wrap for covering, and no condiments were provided. Staff also reported that they frequently had to return to the kitchen for additional items, further delaying meal service and contributing to the temperature issues. Interviews with dietary and environmental services managers confirmed that the insulated carts could only keep food hot for 20-30 minutes, depending on how often the cart was opened. Staff on the units were responsible for serving the trays, but many residents were not ready to eat when the carts arrived, causing further delays. Residents were not routinely offered the option to have their meals reheated, and some reported that even cold items, such as ice cream, were served warm. The administrator acknowledged that food was plated in the kitchen and brought to the units on insulated carts, and that hot food should be served according to facility policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents. In the first incident, an activity aide overheard a resident making derogatory comments about another resident, accusing them of inappropriate behavior. The aide did not report these comments to the staff responsible for the residents' care. Subsequently, the resident who made the comments entered the other resident's room and physically assaulted them, resulting in the victim being sent to the hospital for evaluation and treatment. In the second incident, a resident left their room and admitted to a hall monitor that they had hit another resident. Despite being questioned by staff, the resident returned to the victim's room and assaulted them again. The staff's failure to immediately separate the residents and prevent further altercation allowed the second assault to occur. The victim was subjected to physical aggression involving the head, and the assailant was sent to the hospital for evaluation. Both incidents highlight the facility's failure to adequately monitor and respond to resident behaviors that posed a risk of abuse. The staff did not intervene promptly or effectively to prevent the assaults, and there was a lack of communication and reporting of concerning behaviors that could have mitigated the risk of harm to the residents involved.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received medications as ordered, leading to deficiencies in care for multiple residents. Resident #15, who had a history of type II diabetes and hypothyroidism, did not receive their prescribed medications, including Ozempic and Toujeo, on several occasions due to unavailability. The facility's policy required that the physician, Director of Nursing (DON), and other relevant parties be notified when medications were unavailable, but there was no documentation of such notifications. Additionally, there was no evidence that a backup pharmacy was contacted to obtain the medications, as per facility policy. Resident #17, diagnosed with chronic pain, also experienced a lapse in medication administration. The resident's prescribed lidocaine patches were not applied on two occasions due to unavailability, and there was no documentation that the physician or other relevant staff were notified. The resident reported experiencing daily back pain and expressed that the patches frequently ran out, yet no alternative pain management was provided. Resident #20, who had been admitted with sciatica and chronic pain syndrome, did not receive the prescribed hydrocodone-acetaminophen following an emergency room visit. The medication was discontinued without proper documentation or physician notification, contrary to the hospital's discharge instructions. The resident expressed confusion and discomfort due to the lack of pain medication. Interviews with staff revealed a lack of communication and adherence to policies regarding medication availability and physician notification, contributing to the deficiencies observed.
Failure to Provide Timely Treatment for Urinary Symptoms
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident who experienced urinary urgency and dysuria. Despite the resident's complaints, staff did not assess or obtain treatment for seven days, nor did they perform a urinalysis as ordered by the physician. This lack of action resulted in the resident being admitted to the hospital with acute pyelonephritis and a complicated urinary tract infection. Upon the resident's readmission to the facility, staff failed to administer four doses of the prescribed antibiotic. The facility's policies required prompt notification of changes in a resident's condition and adherence to physician orders, but these were not followed. The resident's medical records showed multiple instances where the prescribed medication was not administered, and there was no documentation of staff notifying the physician about the missed doses. Interviews with the resident, the Director of Nursing, the Administrator, and the Medical Director revealed that staff did not adequately assess the resident's condition or communicate effectively with the physician. The resident expressed dissatisfaction with the care received, noting that staff did not act on their symptoms or arrange for hospital transfer until requested. The Medical Director confirmed that he was not informed of the resident's condition, which could have prevented the hospitalization if addressed promptly.
Resident's Dignity Compromised by LPN's Actions
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Licensed Practical Nurse (LPN) and a resident. The resident, who had diagnoses of depression, weakness, and abnormal gait and mobility, was leaving the dining room with a cup of red drink mix. The resident's care plan indicated behaviors of agitation and anxiety, with triggers including being yelled at and arguing. The resident was also noted to have impaired communication due to difficulty hearing. On the day of the incident, the resident attempted to take a cup from the dining room back to their room, which led to a confrontation with LPN A. LPN A stopped the resident from taking the cup, offering a disposable cup instead. However, the resident attempted to take the cup back, resulting in the drink mix spilling on both the resident and LPN A. Multiple interviews with staff and other residents confirmed that LPN A was disrespectful and that the resident was upset following the incident. Witnesses described LPN A as having grabbed the cup from the resident's box of personal items, leading to the drink mix being spilled on the resident's face and clothes. The resident expressed anger and upset over the incident, and other residents corroborated the account of LPN A's actions. The Director of Nursing and the Administrator both acknowledged that LPN A's actions were disrespectful and not in line with the facility's expectations for treating residents with respect. The facility's policy on dignity and respect emphasized that every resident had the right to be treated with dignity and respect, and that staff should speak to and treat all residents accordingly. The incident highlighted a failure to adhere to this policy, resulting in a deficiency in the care provided to the resident.
Failure to Provide Protective Oversight for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide protective oversight for a resident with psychiatric diagnoses and a history of suicidal ideation. This resident, who lived on a secured behavioral unit, obtained a disposable razor from another resident and used it to cut their wrist several times. The incident occurred after the resident borrowed the razor under the pretense of wanting to shave without staff supervision. The resident had a history of self-harm and suicidal ideation, which was documented in their care plan and PASARR evaluations. The resident's care plan highlighted their history of impulsive behavior, poor judgment, and suicidal ideation, which required protective oversight in a secure setting. Despite these documented needs, the facility did not have a specific policy regarding the use and management of razors by residents. This lack of policy contributed to the resident's ability to access a razor unsupervised, leading to the self-harm incident. Interviews with residents and staff revealed that the razor was not properly accounted for or managed, as it was left in a resident's possession for several weeks. The facility's failure to ensure that razors were returned to staff and disposed of in a sharps container after use directly contributed to the incident. The administrator acknowledged that residents should be supervised with razors and that the facility lacked a system to track or count razors, which was a significant oversight in maintaining a safe environment for residents.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident entered their room and initiated a verbal argument that escalated into physical violence. The incident involved Resident #1, who had a history of behavioral issues, including oppositional defiant disorder and intellectual disabilities, and Resident #2, who was cognitively intact but had a history of anxiety, depression, and borderline personality disorder. Resident #1, upset over comments made about a friend, entered Resident #2's room and, after a verbal altercation, physically assaulted Resident #2 by hitting them in the head and neck, resulting in a neck contusion. Certified Nurse Aide (CNA) F was assigned to one-on-one supervision of Resident #2 at the time of the incident but failed to intervene or prevent the assault. Despite being present in the room, CNA F did not take action to stop Resident #1 from attacking Resident #2, citing a lack of training on handling physical aggression. Hall Monitor I, who was nearby, attempted to intervene but was unable to prevent Resident #1 from striking Resident #2. The facility's investigation confirmed that Resident #1 had a history of poor impulse control and aggressive behavior, which contributed to the incident. The facility's policies on abuse and neglect emphasize the importance of staff intervention in situations of resident-to-resident altercations. However, CNA F reported not receiving adequate training on one-on-one supervision or managing aggressive behavior, which contributed to the failure to protect Resident #2. The incident highlights a deficiency in the facility's implementation of its abuse prevention policies, as staff did not effectively intervene to prevent the physical assault, resulting in harm to Resident #2.
Failure to Administer Prescribed Medications to Resident with Mental Disorders
Penalty
Summary
The facility failed to provide individualized treatment and services to a resident with mental disorders, including bipolar disorder and schizophrenia, who resided in a secured locked unit. The resident's care plan required the administration of medications as ordered, but the facility did not ensure the timely and appropriate administration of prescribed medications, such as Wellbutrin XL and Abilify. The resident missed multiple doses of these medications due to issues with insurance preauthorization and availability, which were not adequately addressed by the facility staff. The resident's progress notes indicated several instances where the resident became agitated and exhibited aggressive behavior due to missed medication doses. Despite the resident's cognitive intactness and awareness of their medication needs, the facility staff failed to administer the medications as scheduled, leading to behavioral emergencies and the resident pulling the fire alarm on multiple occasions. The facility's staff did not consistently follow up with the pharmacy or notify the physician to obtain alternative medications when the prescribed ones were unavailable. Interviews with facility staff, including LPNs and the DON, revealed a lack of communication and documentation regarding the unavailability of medications. The staff did not consistently report missed medications in nursing meetings or take appropriate steps to resolve the issues, such as contacting the pharmacy or the resident's physician. The resident expressed feelings of neglect and reported not seeing the psychiatrist for two months, further highlighting the facility's failure to provide necessary behavioral health services.
Inadequate Food Service and Portion Control
Penalty
Summary
The facility failed to ensure proper serving sizes and alternative options for residents with a regular diet order. Observations and interviews revealed that residents were not consistently receiving the correct portion sizes, and there was a lack of alternative vegetables when residents disliked the ones served. The facility's policy on standardized portions was not followed, as dietary staff did not consistently use portion control utensils, leading to inconsistent serving sizes. Additionally, the facility did not provide alternative vegetables when residents expressed a dislike for the ones served, contrary to the facility's policy on substitutions. Multiple residents reported dissatisfaction with the food service, stating that they were often left hungry after meals due to insufficient portions and a lack of variety in both meals and snacks. Residents expressed that they were not always able to receive seconds, and the snacks provided were limited to items like Cheez-Its, which were not substantial enough to satisfy their hunger. The facility's policy on snacks indicated that a variety of snacks should be available, but residents reported a lack of options. Interviews with dietary staff and management revealed a lack of awareness and adherence to the facility's policies. Dietary Aide B was unsure of the correct serving sizes and was not instructed to provide alternative vegetables. The Dietary Manager acknowledged hearing concerns about snacks but had not considered offering alternative vegetables. The administrator was unaware of residents' concerns about hunger and snacks, indicating a communication gap between residents and management. These deficiencies highlight a failure to meet residents' nutritional needs and preferences as outlined in the facility's policies.
Failure to Serve Palatable and Safe Temperature Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at a safe and appetizing temperature. Multiple residents expressed dissatisfaction with the taste and temperature of the food, with some stating that the food was not warm when served and lacked variety. The facility's policy required hot foods to be served at temperatures greater than 135 degrees Fahrenheit, but observations showed that the food served was significantly below these temperatures. For instance, a test tray prepared for lunch showed chicken parmesan at 106 degrees Fahrenheit, buttered pasta at 92 degrees Fahrenheit, and buttered peas at 98 degrees Fahrenheit, all of which were under the acceptable serving temperatures. Interviews with dietary staff revealed inconsistencies in the expected serving temperatures, with one dietary aide stating that hot foods should be served at 110 degrees Fahrenheit, while the dietary manager expected hot food to be served at 140 degrees Fahrenheit from the steam table and at least 120 degrees when served to residents. The administrator acknowledged that residents frequently voiced concerns about food temperatures and expected staff to address these concerns by contacting dietary for a new tray or offering to warm the food. Despite these expectations, the facility did not consistently meet the required standards for food temperature and palatability.
Misappropriation of Resident Funds by Staff Member
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their money by a staff member. The incident involved a resident who, along with another resident, gave $40.00 to a Hall Monitor through a cash app transaction. The money was intended for the purchase of a THC vape pen. The resident, who had a history of mental health issues including bipolar disorder, autism, and paranoid schizophrenia, did not receive the item they paid for and was unable to recover the money. The resident expressed distress over the loss of their money to a staff member. The facility's investigation revealed that the Hall Monitor accepted the $40.00 transaction from the resident via another resident's cash app account. The Hall Monitor was found to have misappropriated the funds, as confirmed by the cash app transaction history. The facility's policy on abuse and neglect, which includes the prohibition of misappropriation of resident property, was not adhered to in this instance, leading to the deficiency.
Inadequate Supervision and Fall Prevention in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight for a resident with behavioral difficulties and a history of mental illness, who required 24-hour monitoring and was at risk for elopement. On a specific date, a hall monitor left residents unattended in a gated courtyard during a smoke break, allowing the resident to use a chair to climb over a 12-foot fence and leave the facility without staff knowledge. The resident was found approximately two miles away after crossing a busy highway, and staff were unaware of the elopement until another resident reported it. The facility lacked a specific policy for monitoring residents during smoke breaks, and the resident's care plan did not address elopement risk or smoking precautions. The resident had a complex medical history, including multiple mental health disorders and a history of self-harm and drug use. Despite being on a secured behavioral unit and requiring intensive monitoring, the resident's care plan was not updated to include interventions for elopement risk as indicated in their PASARR evaluations. The facility's failure to implement and communicate necessary interventions contributed to the resident's ability to elope. Interviews with staff revealed that the hall monitor left the smoke area unattended to answer a call light, and there was a lack of documentation on the number of residents who went out to smoke and returned inside. Additionally, the facility failed to consistently implement interventions to prevent falls for another resident with a history of falls and injuries. Despite multiple falls, the resident's care plan was not updated with new interventions after each incident. The resident had several diagnoses, including dementia and COPD, and required assistance with daily activities. The facility's policies on fall prevention and post-fall protocols were not adequately followed, as evidenced by the lack of updates to the resident's care plan and the high fall risk score. The facility's inaction in addressing these deficiencies led to an Immediate Jeopardy situation, which was later removed after surveyor verification.
Inadequate Staffing and Training for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient staff with the appropriate competencies and skills were employed to meet the behavioral health needs of residents on locked behavioral health units. Staff from non-nursing departments such as activities, laundry, housekeeping, and maintenance were frequently pulled from their regular duties to provide one-on-one (1:1) monitoring for residents experiencing behavioral health crises. This practice resulted in the closure or limited access to the Hangout, a common recreation area, affecting the residents' ability to engage in activities and access outdoor spaces. The facility's staffing plan and daily staffing sheets revealed that the facility was understaffed, with key positions such as the Director of Nursing (DON) being pulled to work as a charge nurse, and aides being fewer than required. The facility's policy on intensive monitoring required that residents needing 1:1 supervision should always have a staff member within eyesight, but the staff assigned to these duties were often not informed of the specific reasons for the monitoring. Interviews with staff members revealed discomfort and lack of knowledge about the residents they were monitoring, which compromised the safety and well-being of both residents and staff. The deficiency was further highlighted by the facility's inability to maintain regular operations in non-nursing departments, leading to missed tasks such as cleaning and activity provision. The limited access to the Hangout area, which was used as a reward for good behavior, led to increased resident frustration and behavioral incidents. The facility's failure to provide adequate staffing and training for behavioral health needs resulted in a compromised environment for both residents and staff.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents or their representatives were involved in the development and implementation of person-centered care plans. Specifically, two residents and their representatives were not invited to routine care plan meetings. The facility's policy mandates the involvement of residents and their families in care planning, but it does not specify the frequency and timing of these meetings. This lack of clarity contributed to the oversight in involving the residents and their representatives. Resident #3, who was cognitively intact and had diagnoses of schizophrenia and PTSD, expressed the importance of having family involved in care discussions. Despite this, there was no documentation of the resident or their representative participating in care plan meetings since admission. The resident's guardian reported attending only one meeting and expressed a desire for more involvement. Similarly, Resident #1, also cognitively intact with diagnoses of bipolar disorder and schizophrenia, had no documented participation in care plan meetings, and their guardian expected to be involved. Interviews with facility staff revealed systemic issues in conducting routine care plan meetings. The MDS Coordinator, who worked part-time at the facility, prioritized MDS assessments over care plan meetings, resulting in missed meetings. The Social Service Director admitted to not consistently documenting meetings and failing to notify residents' representatives. The Director of Nursing was unaware of the frequency and attendance of care plan meetings, and the administrator expected routine completion of these meetings, highlighting a lack of coordination and communication among staff.
Failure to Follow Up on Biopsy Results and Ensure Timely Treatment
Penalty
Summary
The facility failed to ensure that a resident received necessary care and services in accordance with professional standards of practice. The resident underwent a left breast needle biopsy after a mass was found, but the facility did not follow up and report the biopsy results to the physician until approximately eight months later. The biopsy results indicated infiltrating duct adenocarcinoma, a common form of breast cancer. Additionally, the facility failed to ensure the resident attended a scheduled follow-up appointment with the oncologist to discuss the treatment plan. The resident's care plan indicated impaired thought processes related to schizophrenia and required assistance with personal hygiene and protective oversight. Despite this, the facility did not have a procedure in place for who was responsible for following up on biopsy results and other pathology reports. The resident's guardian and the Assistant Director of Nursing were unaware of the biopsy results until much later, and the Director of Nursing admitted to being short-staffed and unable to follow up on such matters. The resident's oncologist confirmed that the biopsy results did not make it back to the primary physician, and the resident missed a crucial follow-up appointment. The oncologist expressed concerns about the potential for disease progression due to the delay in treatment. The resident was eventually diagnosed with stage I breast cancer and scheduled for further diagnostic procedures and treatment, but the delays in care could have affected the outcomes.
Failure to Provide Individualized Treatment for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that three residents with mental disorders received individualized treatment and services to meet their needs. These residents displayed verbal and physical behaviors on multiple occasions, and the facility did not adequately develop and implement meaningful interventions, including non-pharmacological interventions and alternate strategies. The facility also failed to ensure that the residents received timely and appropriate treatment or services to address their psychosocial well-being. The facility's Behavioral Emergency Policy was not followed, and there was a lack of documentation and evaluation of the residents' behaviors and interventions. Resident #1 had a history of bipolar disorder, OCD, ADHD, Asperger's syndrome, adjustment disorder, and polysubstance abuse disorder. The resident displayed acting-out behaviors, verbal aggression, and physical aggression towards peers and staff. Despite multiple incidents of agitation and aggression, the facility did not attempt to identify the root cause of the resident's behavior or revise the plan of care with measurable goals and interventions. The resident's care plan and medical records showed no evidence of evaluation or implementation of new interventions after the resident's behaviors. Resident #2 had a history of schizoaffective disorder, bipolar disorder, pyromania, ADHD, generalized anxiety disorder, ODD, major depressive disorder, intermittent explosive disorder, conduct disorder, substance use, PTSD, paranoid personality disorder, mild intellectual disability, learning disability, and TBI. The resident displayed verbal and physical aggression towards peers and staff. The facility did not identify the root cause of the resident's behavior or implement new interventions after the resident's behaviors. The resident's care plan and medical records showed no evidence of evaluation or implementation of new interventions after the resident's behaviors.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
