Adair Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Missouri.
- Location
- 1801 North Gaines Drive, Clinton, Missouri 64735
- CMS Provider Number
- 265347
- Inspections on file
- 17
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Adair Village during CMS and state inspections, most recent first.
A resident with dementia, diabetes, kidney disease, and neurologic neglect syndrome had severe unplanned weight loss, dropping more than 15% of body weight in about three months. Staff did not fully notify the MD, DM, or RD, did not implement the RD’s increased TwoCal recommendation in the POS/MAR, did not document meal intake, and did not consistently provide assistance or encouragement during meals. During observation, the resident struggled to eat regular-textured food, left the dining room early, and ate less than 10% of the meal.
The facility failed to provide a SNFABN or alternative denial letter when Medicare Part A skilled services were initiated, reduced, or terminated for two residents who remained in the facility after covered services ended. Although NOMNCs were given by phone to family representatives with verbal acknowledgement, staff did not give the resident or legal representative the required written notice of potential liability, and the SSD and administrator stated they were unaware of the requirement.
Missing Written Transfer and Bed-Hold Notices: The facility did not ensure written transfer notices and bed-hold information were provided for three residents sent to the hospital. Records showed each resident had acute medical issues such as COPD, respiratory failure, pneumonia, sepsis, or dementia, and staff documented emergency transfers or hospital admissions, but there was no documentation that written notices were given or mailed to the resident or representative. Interviews showed staff typically called family and sent clinical paperwork, but were not aware of written transfer notices being provided.
Insulin pen administration errors exceeded the allowed rate when an LPN failed to prime pens and did not hold the pen in place after injection for three residents with diabetes. Observations showed the LPN administered Humalog/insulin lispro to residents with orders for sliding-scale, scheduled premeal, and evening doses without priming the pen and without waiting after pushing the plunger, resulting in 3 errors out of 26 opportunities (11.54%). Interviews with nursing leadership confirmed pens should be primed every time and held in place after administration.
Insulin pens were not primed before administration and the pen was not held in place after injection for three residents receiving insulin lispro. An LPN administered insulin to residents with diabetes-related diagnoses without following the manufacturer’s instructions, and interviews with nursing leadership confirmed that pens should be primed every time and held in place after the dose is given.
A resident admitted with ESRD and dialysis dependence did not have a baseline care plan completed within the required 24 to 48 hours. The plan was dated 4 days after admission, and the 48-hour care plan was dated 5 days after admission. Records showed the resident was legally blind, used a walker, needed assistance with ADLs, and attended dialysis M/W/F. Staff including the RN, MDS coordinator, LPN, ADON, DON, and Administrator stated the baseline care plan should have been completed within 24 to 48 hours.
Missing Documentation for New Schizophrenia Diagnosis: The facility failed to provide sufficient medical documentation to support a new schizophrenia diagnosis for a resident receiving Seroquel. Physician progress notes and nursing notes did not document a psychiatric evaluation or symptoms supporting schizophrenia, and a pharmacy fax requested the physician select schizophrenia as the medication indication. Staff interviews showed the MDS coordinator believed the diagnosis was based on the pharmacy recommendation, while the DON stated a new mental health diagnosis should include rationale, physician notification, and behavior documentation.
A resident with ESRD and dependence on renal dialysis did not have physician orders documented for dialysis or for assessment of the dialysis site, and the chart lacked a specific dialysis policy. Although the care plan noted hemodialysis on M/W/F and staff discussed checking the shunt site, staff interviews showed they were unsure whether the required orders were in place. The resident reported leaving very early for dialysis and returning later for breakfast.
Failure to use EBP and perform hand hygiene during resident care. Two CNAs provided personal care to a resident with a urinary catheter without wearing gowns, handled the catheter bag during care, and one CNA was not observed removing gloves or washing hands when leaving the room. The resident was dependent on staff for all care and had an order and care plan for EBP due to the catheter. Staff interviews confirmed that gowns, gloves, and hand hygiene were expected during care.
A resident with multiple medical conditions and a care plan requiring two-person assistance for transfers and changing was left unattended by a single nurse assistant, despite clear documentation and staff awareness of the need for two staff. The resident fell from bed during care, resulting in a fractured humerus. Staff interviews confirmed that the requirement for two-person assistance was well known and communicated throughout the facility.
Two nurse aides worked beyond four months without completing state-approved CNA training, competency evaluation, or certification, and continued to provide direct care to residents. Both aides started classes late and were scheduled for testing after the required timeframe, contrary to facility policy and federal requirements.
Nursing staff failed to document the administration of scheduled medications for three residents with complex medical conditions, leaving blank spaces in the MAR without explanation or required codes. This included missed documentation for critical medications such as anticoagulants, antidepressants, antihypertensives, and pain medications. Interviews with staff confirmed that all medication administrations should be recorded, and blank MAR entries indicate either non-administration or lack of documentation, with no further information found in the medical records.
Staff did not consistently document the administration of a physician-ordered 2 Cal nutritional supplement for a resident with significant weight loss and multiple health conditions, despite care plans and orders requiring it three times daily. Medication Administration Records showed several missed or undocumented doses, and staff interviews confirmed that documentation was expected for both administration and refusals. This failure to document or administer the supplement as ordered resulted in a deficiency related to maintaining the resident's nutritional status.
Staff failed to consistently document and administer ordered oxygen therapy for a resident with multiple respiratory and cardiac conditions. Multiple shifts lacked documentation of oxygen administration, and staff did not record reasons for missed checks, despite facility policy and physician orders requiring this. Interviews confirmed that nurses are responsible for this documentation, and blank spaces on records indicated the task was not completed.
A resident with multiple health conditions experienced significant delays in receiving pain medication, despite visible discomfort and repeated requests. The resident waited over three hours for tramadol, which was eventually administered by the DON without proper documentation or pain assessment. Staff interviews revealed communication and documentation lapses, contributing to the deficiency in pain management.
A resident with multiple health conditions and at risk for pressure ulcers did not receive proper wound care in a LTC facility. Staff failed to document and treat wounds on the resident's knee, legs, and buttocks according to facility protocols. The DON acknowledged the lack of physician orders for these wounds, and the resident's physician was unaware of all the wounds. Observations showed inadequate treatment, and staff interviews revealed a lack of awareness and documentation.
A resident experienced an improper transfer resulting in bruising and swelling due to rough handling by a CNA. Despite reporting the incident, the facility failed to document or investigate the injury, violating protocols for skin assessments and communication. The resident's care plan highlighted a risk for bruising, yet staff did not adhere to procedures for reporting new skin issues.
Failure to Address Significant Weight Loss and Meal Assistance Needs
Penalty
Summary
The facility failed to provide enough food and fluids to maintain a resident’s health for a resident with multiple diagnoses including heart disease, kidney disease, dementia, diabetes, high blood pressure, and neurologic neglect syndrome. The resident had severe cognitive impairment, required assistance with most activities of daily living, and needed supervision and set-up assistance for eating. The resident was identified as being at risk for weight loss and had a documented unplanned weight loss, but the facility did not fully inform the physician, involve the Dietary Manager, or notify the consultant RD for assessment when the weight loss became significant. The resident’s weight declined from 137.5 pounds to 115.8 pounds over about three months, a loss of 21.7 pounds or 15.78%. The facility policy required verification of significant weight changes, notification of the dietician, and multidisciplinary evaluation of undesirable weight loss, including assessment of causes, intake, and individualized interventions. Although the care plan included supplements, weekly weights, diet modification, and monitoring for weight loss, the physician order sheet did not reflect the RD’s recommendation to increase TwoCal from 30 ml to 60 ml three times daily, and the medication administration record did not show that increase. Staff also did not document meal intake, and no Dietary Manager notes were found in the record. During observation, the resident was served regular textured food on a regular plate rather than in bowls, despite poor vision and prior discussion of using bowls. The resident struggled to eat with a fork, spilled food, appeared frustrated, left the dining room before finishing, and ate less than 10% of the meal. No staff approached or encouraged the resident during the meal, and the meal intake was not documented. Interviews with nursing, dietary, and administrative staff showed they were aware the resident had weight loss and that staff should have sat with and assisted the resident, documented intake, and implemented the RD’s recommendation, but these actions were not consistently carried out. The Medical Director stated he had not been notified of the resident’s weight loss or the RD’s recommendations.
Failure to Provide SNFABN or Denial Letter for Medicare Part A Termination
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, CMS-10055) or an alternative denial letter when Medicare Part A skilled nursing services were initiated, reduced, or terminated for two residents who remained in the facility after Medicare-covered services ended. Record review showed that for one resident, Medicare A skilled services began on 12/22/25 and the last covered date was 01/20/26; for the other resident, Medicare A skilled services began on 10/31/25 and the last covered date was 12/11/25. In both cases, the facility/provider initiated discharge from Medicare Part A services before the benefit days were exhausted. For both residents, a Notice of Medicare Non-Coverage (NOMNC, CMS-10123) was provided by phone to a family representative with verbal acknowledgement, but staff did not provide the resident or legal representative with the SNFABN or an alternative denial letter. The social service designee stated she did not know an ABN was needed, and the administrator stated that she and the SSD did not know the requirement to provide the SNFABN or alternative denial letter for residents remaining in the facility.
Missing Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that residents or their representatives received written notice of transfer and bed-hold information when residents were sent to the hospital. The report states that the facility did not have a process in place to routinely provide transfer letters and notice of bed hold for three sampled residents who were transferred to acute care settings. Facility policies dated March 2025 and October 2022 required written transfer or discharge notices, written bed-hold information, and documentation of attempts to notify representatives when emergency transfers occurred. For Resident #57, the record showed diagnoses including COPD with acute exacerbation and encephalopathy. Nursing notes documented that on 11/15/25 the resident became weak, slumped over on the toilet, was later shaking and very drowsy, and was evaluated by the charge nurse and physician. The resident refused hospital transfer at that time, but was admitted to the hospital on 11/16/25. The medical record did not contain documentation that a written transfer notice was given or mailed to the resident or representative for this hospital transfer. For Resident #25, the record showed diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and hypokalemia. Nursing notes documented oxygen desaturation into the low 80s while on oxygen, confusion, diminished lungs with crackles, and physician notification; EMS transported the resident to the emergency room on 11/8/25. The resident returned from hospitalization on 11/11/25 with pneumonia and acute on chronic respiratory failure with hypoxia and hypercapnia. The medical record did not contain documentation of a written transfer notice given or mailed to the resident or representative for the 11/8/25 hospital transfer. For Resident #7, the record showed diagnoses including COPD, pneumonia, severe sepsis with septic shock, and dementia. Nursing notes documented that on 12/31/25 the resident complained of not feeling well, was shaking and light-headed, had elevated blood pressure and pulse, and had oxygen saturation of 87% on 3 liters of oxygen; the physician suggested sending the resident to the emergency room and the family was notified. The resident returned to the facility on 01/07/26 with a PICC line and IV antibiotics. The medical record did not contain documentation of a written transfer notice given or mailed to the resident or representative for the 12/31/25 hospital transfer. Interviews with the Social Service Director, nursing staff, MDS Coordinator, ADON, DON, and Administrator confirmed that staff were aware of phone notification and sending clinical paperwork, but were not aware of written transfer notices being sent to residents or families.
Insulin Pen Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medication error rates remained below 5% when staff did not prime insulin pens and did not follow the manufacturer’s administration instructions for three residents. Surveyors identified 3 medication errors out of 26 opportunities, resulting in an error rate of 11.54%. Facility policies stated that medications are to be administered safely and in accordance with prescriber orders, and the insulin administration policy required staff to have access to manufacturer instructions for insulin delivery systems before use. Resident #8 had diagnoses including type 2 diabetes mellitus and metabolic encephalopathy and had an order for Humalog Kwikpen before meals based on sliding scale blood glucose results. During observation, an LPN prepared the resident’s insulin, obtained a blood glucose of 216, administered the insulin into the left lower abdomen, did not prime the pen, and did not hold the needle in the skin for at least five seconds after pushing the plunger. Resident #44 had diagnoses including cerebrovascular disease and type 2 diabetes mellitus and had an order for insulin lispro 10 units before meals. During observation, the LPN turned the pen dial to 10 units, administered the insulin into the left upper arm, did not prime the pen, and did not hold the needle in the skin for at least five seconds. Resident #4 had diagnoses including stroke, type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease stage 3 and had an order for insulin lispro 8 units in the evening. During observation, the LPN obtained the insulin pen, dialed it to 8 units, administered the insulin into the left lower abdomen, did not prime the pen, and did not hold the pen in the skin for any length of time. Interviews with nursing staff, the ADON, DON, and Administrator confirmed that insulin pens should be primed every time and held in place after administration to ensure the full dose is delivered.
Insulin Pens Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when insulin pens were not primed before administration and the manufacturer’s instructions for use were not followed. The report identified this issue during observations, interviews, and record review for three residents who received insulin lispro by pen. Facility policy defined medication errors as administration not in accordance with physician orders, manufacturer specifications, or accepted professional standards, and the insulin pen instructions required priming before each injection and holding the pen in the skin after injection. Resident #8 had diagnoses including type 2 diabetes mellitus and metabolic encephalopathy and had an order for Humalog Kwikpen before meals based on sliding scale blood glucose results. During one observation, an LPN prepared supplies, obtained a blood glucose of 216, wiped the resident’s abdomen, and administered insulin without priming the pen and without holding the needle in the skin for any length of time after pushing the plunger. During a second observation, another LPN entered the room with an insulin pen, turned the dial to two units, and administered the insulin without priming the pen. Resident #44 had diagnoses including cerebrovascular disease and type 2 diabetes mellitus and had an order for insulin lispro 10 units before meals. During observation, an LPN turned the pen dial to 10 units, wiped the resident’s upper arm, and administered the insulin without priming the pen and without holding the needle in the skin for any length of time after pushing the plunger. During a second observation, the same resident received insulin from another LPN who turned the dial to 10 units and administered the insulin without priming the pen. Resident #4 had diagnoses including stroke, type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease stage 3 and had an order for insulin lispro 8 units in the evening. During observation, an LPN obtained the insulin lispro pen from the medication cart, turned the dial to 8 units, and administered the insulin to the resident’s abdomen without priming the pen and without holding the pen in the skin for any length of time. Interviews with nursing staff, the ADON, DON, and Administrator confirmed that insulin pens should be primed every time and that the pen should be held in place after administration to ensure the full dose is delivered.
Baseline care plan not completed within required timeframe
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident. Facility policy titled Baseline Care Plans, dated March 2022, required a baseline plan of care to be developed within 48 hours of admission to address the resident’s immediate health and safety needs and to include initial goals, physician orders, dietary orders, therapy services, and social services. The policy also stated the baseline care plan would be used until the comprehensive care plan was developed. Resident #60 was admitted on 01/15/26 with diagnoses including end stage renal disease and dependence on renal dialysis. The resident’s admission MDS showed the resident was admitted to the facility on 01/15/26. The resident’s baseline care plan was dated 01/19/26, which was 4 days after admission. That baseline care plan documented that the resident was on dialysis Monday, Wednesday, and Friday; could communicate easily with staff; required supervision or touching assistance with toileting hygiene, dressing, personal hygiene, and transfers; required partial to moderate assistance with showering; used a walker; and was cognitively intact. The resident’s 48-hour care plan, used with the initial care plan, was dated 01/20/26, 5 days after admission. It listed an admitting diagnosis of renal disease and participation in treatment for long term care placement. The comprehensive care plan, also dated 01/20/26, addressed hemodialysis, monitoring for complications, avoiding blood pressure and blood draws in the graft arm, encouraging dialysis attendance, monitoring labs, and watching for signs and symptoms of renal insufficiency. Nursing progress notes on 01/15/26 documented the resident arrived by private car, ambulated to the room on own, had a shuffled gait, was legally blind, attended dialysis Monday, Wednesday, and Friday at 5:15 A.M., was on a regular diet, and voiced a desire to follow a renal diet even though the facility did not offer special diets. During interviews, the Social Service Director, RN, MDS Coordinator, LPN, ADON, DON, and Administrator all stated the baseline care plan should have been completed within 24 to 48 hours of admission and should not have been started 4 days after admission.
Missing Documentation for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to provide sufficient medical documentation to support a new mental health diagnosis of schizophrenia for one resident. The resident had an admission diagnosis of cerebral infarction and existing diagnoses of bipolar disorder and schizophrenia was later added to the face sheet. The resident’s quarterly MDS showed cognitive impairment, wheelchair use, and bowel and bladder incontinence, and the care plan noted use of psychotropic, antianxiety, and antidepressant medications along with periods of verbally aggressive behavior. Review of the resident’s physician progress notes on 9/7/25, 10/5/25, and 11/2/25 showed no psychiatric evaluation or documentation supporting the new schizophrenia diagnosis. Nursing notes from 9/21/25 to 10/21/25 and from 10/21/25 to 11/21/25 also showed no documentation of symptoms supporting schizophrenia and no documentation of the added diagnosis. A pharmacy recommendation fax on 10/30/25 asked the physician to choose schizophrenia, Huntington’s disease, or Turret’s syndrome as the indication for Seroquel, and the physician response section indicated schizophrenia, but the response was not signed. During interviews, nursing staff stated they document behaviors and symptoms each shift and report changes to the DON or ADON, while the MDS coordinator said he/she handles PASRR issues and believed the schizophrenia diagnosis was based on the pharmacy recommendation. The physician said he/she had treated the resident for over two years, that Seroquel was necessary for mood and behavior management, and that he/she did not recall the added schizophrenia diagnosis but would not argue with it because the resident had many schizophrenia-like symptoms. The DON stated documentation of a new mental health diagnosis should include a rationale, physician notification, and documentation of behaviors and symptoms, and the Administrator said staff were expected to document on residents with a new mental health diagnosis.
Missing Dialysis Orders and Site Monitoring
Penalty
Summary
The facility failed to provide dialysis services per professional standards of practice for a resident with end stage renal disease and dependence on renal dialysis. The resident was admitted with diagnoses including ESRD and renal dialysis dependence, and the record showed the resident attended dialysis on Monday, Wednesday, and Friday at 5:15 A.M. The facility’s dialysis communication forms were present in the chart, and the care plan identified that the resident needed hemodialysis every Monday, Wednesday, and Friday, but the physician order sheet did not document an order for dialysis or an order for assessment of the dialysis site. The care plan also did not include information about the time of dialysis or which arm was affected. The record review and interviews showed the facility lacked a specific dialysis policy. Staff members, including the RN, LPN, ADON, DON, and Administrator, stated that residents on dialysis should have physician orders and that the shunt site should be checked, but they did not know whether the resident had the needed orders. The resident stated he/she left the facility at about 5:00 A.M. for dialysis and did not receive breakfast until after returning. The facility’s admission summary noted the resident was legally blind, ambulatory with a shuffle gait, and pleasant during assessment, and the comprehensive care plan included monitoring for signs and symptoms of renal insufficiency and avoiding blood pressure or blood draws in the graft arm.
Failure to Use EBP and Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain a complete infection control program when staff did not use Enhanced Barrier Precautions (EBP) during personal care for a resident with an indwelling urinary catheter and did not complete proper hand hygiene during resident care. The resident had diagnoses including chronic kidney disease, Alzheimer's disease, and atherosclerotic heart disease, was severely cognitively impaired, rarely able to make self understood, and dependent on staff for all care. The resident's care plan identified infection risk related to the catheter and directed staff to use EBP, and the physician order also required EBP due to the catheter. During observation of care, two CNAs entered the resident's room wearing gloves but not gowns. They removed the resident's pants and incontinence brief, assisted the resident to roll, placed a new brief and Hoyer lift pad, fastened the brief and pants, and handled the catheter bag by placing it in the resident's lap and later into the dignity bag attached to the wheelchair. One CNA then brushed the resident's hair while the other gathered trash and made the bed. One CNA was not observed removing gloves or washing hands when leaving the room, and the other CNA removed gloves and washed hands. The resident's catheter bag was handled during care, and staff did not don gowns as required for EBP. Staff interviews confirmed knowledge of EBP and hand hygiene expectations, including wearing gowns and gloves for residents with catheters and washing hands before and after resident contact and when moving from dirty to clean tasks. The CNA involved stated a gown was forgotten during care, and the other CNA stated the same. RN, LPN, ADON, DON, and the Administrator all stated that residents with catheters should be on EBP and that staff should wear gowns and gloves and perform hand hygiene during resident care.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Fracture
Penalty
Summary
Staff failed to provide care as required by the resident's care plan and facility policy, resulting in a fall and injury. The resident involved had multiple diagnoses, including cerebral infarction, congestive heart failure, metabolic encephalopathy, and was on anticoagulant medication. The care plan specified that the resident was at risk for falls, was totally dependent on staff for repositioning and transfers, and required a mechanical lift with the assistance of two staff members for all transfers and changing. Despite these documented requirements, a nurse assistant provided care to the resident alone after the resident requested to be changed immediately. The nurse assistant acknowledged being aware that two staff were required for such care, as indicated on the care plan and signage in the resident's room, but proceeded to change the resident without waiting for assistance. During the process, the resident rolled in the opposite direction as instructed and fell from the bed, resulting in a fracture to the left humerus. Multiple staff interviews confirmed that the resident was known to require two staff for all transfers and changing, and that this information was communicated through care plans, door signage, and staff reports. The incident was further corroborated by interviews with other nurse assistants, a certified medication technician, a physical therapist, the resident's physician, and facility leadership, all of whom stated that two staff were required for the resident's care due to the resident's size, lack of mobility, and cognitive status. The failure to follow the established care plan and facility policy directly led to the resident's fall and injury.
Failure to Ensure Timely CNA Training and Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months completed a state-approved certified nursing assistant (CNA) training program, competency evaluation, and certification within the required timeframe. Two nurse aides, both hired in August, began their CNA classes in late October and completed them at the end of January of the following year. However, both were scheduled to take the CNA test in early March, which is beyond the four-month period allowed for completion of training and certification. Review of the state agency CNA registry confirmed that neither aide was listed as a CNA at the time of the survey. Interviews with the nurse aides revealed that they had been providing direct care to residents since their hire dates, with one aide stating they were paired with a CNA for about five days before working independently. Observations confirmed that these aides were actively providing care. The facility's policy and statements from the CNA instructor and administrator indicated an understanding of the four-month requirement, but the aides continued to work beyond this period without certification or completion of the competency evaluation.
Failure to Document Medication Administration as Ordered
Penalty
Summary
Facility nursing staff failed to ensure that all residents received care and treatment in accordance with professional standards of practice by not documenting the administration of medications as ordered by physicians for three residents. The facility's policy requires medications to be administered and documented in the Medication Administration Record (MAR) according to prescriber orders, with any deviations or omissions to be clearly noted and explained. However, multiple instances were identified where staff left blank spaces in the MAR, indicating either a failure to administer the medication or a failure to document its administration, without any accompanying explanation or code. For one resident with complex medical needs including diabetes, stroke, heart failure, and other chronic conditions, staff did not document the administration of several critical medications such as anticoagulants, antidepressants, antihypertensives, and others on multiple occasions. The MARs for this resident showed repeated blank entries for both morning and evening doses across several days, and there was no documentation in the nurses' notes to explain these omissions. Similar patterns were observed for two other residents with significant medical histories, including chronic pain, depression, anxiety, neuropathy, respiratory failure, and cardiovascular disease. For these residents, staff also failed to document the administration of various scheduled medications, including pain medications, antidepressants, diuretics, and antibiotics, with no corresponding notes or explanations in the medical records. Interviews with facility staff, including a Certified Medication Technician, an LPN, the Director of Nursing, and the Administrator, confirmed that the expectation is for all medication administrations to be documented in the MAR, with reasons provided for any missed doses. Staff acknowledged that blank spaces in the MAR indicate either non-administration or lack of documentation, and that such blanks would not automatically trigger a concern during management review. The lack of documentation for administered or missed medications was consistent across all three residents reviewed, and no additional information was found in the nurses' notes to account for the missing entries.
Failure to Document Administration of Dietary Supplement for Resident with Weight Loss
Penalty
Summary
Staff failed to consistently document the administration of a physician-ordered dietary supplement for a resident with significant weight loss and multiple medical conditions, including dementia, severe cervical fracture, hypertension, and dysphagia. The resident experienced notable weight loss over several months, with records showing a 12.6-pound decrease in one month and a body mass index in the underweight range. The care plan and physician orders required the administration of a 2 Cal nutritional supplement three times daily with meals, as well as additional interventions to address the resident's nutritional needs. Review of the Medication Administration Records (MAR) for January and February revealed multiple instances where staff did not document the administration of the 2 Cal supplement at various meal times. Specifically, there were several dates where the supplement was not recorded as given during breakfast, lunch, or dinner. Interviews with dietary and nursing staff confirmed that the supplement was to be provided at each medication pass, and refusals or administrations should have been documented in the MAR. However, blank spaces in the MAR indicated either a lack of documentation or a failure to administer the supplement as ordered. The facility's policy required regular monitoring and documentation of interventions for residents with weight loss, including the use of supplements. Despite these requirements, the lack of consistent documentation for the prescribed supplement represented a failure to ensure the resident received all recommended interventions to maintain acceptable nutritional status. This deficiency was confirmed through record review and staff interviews, which highlighted the importance of accurate documentation for residents at risk of further weight loss.
Failure to Document and Administer Ordered Oxygen Therapy
Penalty
Summary
Facility staff failed to provide respiratory care in accordance with standards of practice by not ensuring documentation of oxygen administration and checks every shift as ordered by the physician for one resident. The resident, who had diagnoses including cerebral infarction, obstructive sleep apnea, congestive heart failure, and acute respiratory failure with hypoxia, had a physician's order for oxygen at two to three liters per nasal cannula every shift for shortness of breath. Review of the Treatment Administration Records (TAR) for January and February showed multiple instances where staff did not document the administration of oxygen on both A.M. and P.M. shifts. Additionally, nurses' notes did not provide explanations for the missed documentation or checks. Interviews with staff, including CNAs, CMTs, LPNs, the DON, and the Administrator, confirmed that nurses are responsible for completing and documenting oxygen administration on the TAR, and that blank spaces indicate the task was not completed. The resident reported that staff had forgotten to replace the oxygen nasal cannula after a mechanical transfer. Facility policy required documentation and assessment for oxygen administration, but these procedures were not consistently followed or recorded for the resident in question.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, leading to a deficiency in care. The resident, who was cognitively intact and required substantial assistance for daily activities, had a history of kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism. Despite having orders for pain management, including lidocaine gel and tramadol, the resident experienced significant delays in receiving pain medication. The resident reported waiting two to three hours for pain relief after requesting medication, which was corroborated by observations of the resident in visible discomfort and interviews with staff. On the day of the incident, the resident requested pain medication in the morning and was observed grimacing and in discomfort throughout the day. Despite multiple requests and visible signs of pain, the resident did not receive tramadol until over three hours later. During this time, the resident was transferred using a mechanical lift, which caused additional pain due to a visibly red, swollen, and bruised arm. The Director of Nursing (DON) eventually administered the medication but failed to document the administration or assess the resident's pain level before or after giving the medication. Interviews with staff, including the DON, revealed a lack of communication and documentation regarding the resident's pain management. The DON was unaware of the resident's need for pain medication until late in the afternoon and did not document the administration of tramadol or the resident's pain level. The facility's failure to administer pain medication timely, assess pain levels, and document the process led to a deficiency in providing appropriate pain management for the resident.
Failure to Document and Treat Resident Wounds
Penalty
Summary
The facility failed to provide care per standards of practice for a resident with multiple wounds. The resident, who was admitted with diagnoses including kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism, was at risk for pressure ulcers. Despite this, staff did not document skin evaluations for several weeks, and when they did, they failed to consistently note the presence of wounds. The resident's care plan was updated to include an open area on the left knee, but staff did not document or care plan for additional sores on the backs of the resident's legs and buttocks. Interviews with staff revealed a lack of awareness and documentation regarding the resident's wounds. The Director of Nursing (DON) acknowledged the presence of wounds on the resident's left knee, bottom, and thighs but noted that there were no physician orders for these areas. The facility's protocol book for wounds was not signed off by a physician, and staff were reportedly following this protocol without specific orders. Observations showed that the resident's wounds were not being treated according to the facility's protocols, with some areas left open and others covered with dry dressings. The resident's physician was not aware of all the wounds and had only referred the resident to a wound care clinic for the knee wound. The physician expected nursing staff to assess, measure, notify, and document new wounds, which was not consistently done. The facility's computer system was supposed to notify staff of due skin assessments, but this process was not effectively followed. Interviews with various staff members, including the Social Services Director and Corporate Nurse, highlighted the expectation for wounds to be documented, monitored, and treated according to protocol, which was not adhered to in this case.
Improper Transfer and Lack of Documentation Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards and provided with adequate supervision during transfers. A resident, who was cognitively intact and required substantial assistance for mobility, experienced an improper transfer that resulted in pain and visible bruising on the arm. The resident was supposed to be transferred using a mechanical sit-to-stand lift but was instead roughly handled by a CNA, leading to significant bruising and swelling. Despite the resident reporting the incident to an LPN and the therapy department, there was a lack of documentation and follow-up on the reported injury. The facility's policy required staff to observe and document any skin issues, but the resident's bruising was not recorded in the skin assessments or progress notes. Interviews with various staff members, including CNAs, LPNs, and the DON, revealed a lack of awareness and communication regarding the resident's condition, with some staff assuming the bruise was pre-existing and not documenting it. The facility's failure to document and investigate the bruising, as well as the improper transfer, highlights a breakdown in communication and adherence to protocols. The resident's care plan indicated a potential for bruising due to anticoagulant therapy, yet the staff did not follow the required procedures for reporting and assessing new skin issues. This deficiency in care and supervision was not addressed or reported to the necessary parties, including the resident's physician and family.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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