Apple Ridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waverly, Missouri.
- Location
- 100 West Thomas Avenue, Waverly, Missouri 64096
- CMS Provider Number
- 265420
- Inspections on file
- 16
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Apple Ridge Care Center during CMS and state inspections, most recent first.
Two residents with behavioral health diagnoses were left unsupervised on a locked unit when a CMT left to retrieve medication records during an internet outage. In the absence of staff, a verbal and physical altercation occurred between the residents over delayed medication administration. Staff interviews confirmed that the unit was left unattended, and facility leadership acknowledged that supervision should have been maintained at all times.
Two residents with psychiatric diagnoses engaged in a verbal and physical altercation when the behavioral health locked unit was left unsupervised by staff. The incident escalated after one resident became upset about delayed medication administration due to an internet outage, leading to yelling and one resident striking the other. Multiple interviews confirmed that no staff were present on the unit at the time, and the facility's policy requiring active protection from abuse was not followed.
Residents without personal phones were required to use the nurses' office phone, where staff presence and the phone's location prevented private conversations. Several residents with mental health and developmental diagnoses reported being unable to make private calls, and staff confirmed that privacy was only offered if specifically requested, with supervision maintained by keeping the office door ajar. The facility had previously provided a portable phone for private use, but this was discontinued, leaving no alternative for residents needing privacy.
A facility failed to protect resident confidentiality when a maintenance director, unaware of HIPAA regulations, disposed of 136 residents' medical records in a public dumpster. The records, labeled with names and years, were accessible until discovered. Other staff, including an LPN and a housekeeper, were aware of proper PHI disposal procedures, but these were not followed in this incident.
The facility failed to maintain a comprehensive infection prevention and control program, particularly for Legionella and TB testing. The Legionella Water Management Plan was incomplete, and several residents did not receive the required two-step TB skin test upon admission. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds or indwelling medical devices, with staff lacking awareness and training on EBP requirements.
The facility failed to provide a comprehensive activities program for residents, affecting their physical, mental, and psychosocial well-being. A resident expressed dissatisfaction with the lack of weekend activities, while another noted that behavior issues among some residents limited their participation. Observations confirmed the absence of activities, and staff interviews revealed that activities were not conducted regularly, especially on weekends, due to the Activities Director's absence.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's specific needs and triggers. Despite having a care plan, staff lacked recent training on PTSD, contributing to inadequate care. The facility's policy required training, but documentation of recent sessions was unavailable.
A facility failed to accurately document narcotic pain medication for several residents, leading to discrepancies between the Medication Administration Record (MAR) and narcotic count logs. Interviews revealed that narcotic counts were not consistently conducted at shift changes, and there were missing signatures on count sheets. Staff admitted to not always counting liquid narcotics, assuming they were full and unopened. The Director of Nursing acknowledged responsibility for ensuring accurate narcotic counts and documentation.
The facility failed to document and provide education on pneumonia vaccinations for five residents upon admission, as required by their policy. Interviews with staff revealed uncertainty about who was responsible for ensuring this education, contributing to the deficiency.
The facility failed to provide and document COVID-19 vaccine education for five residents and five staff members. Interviews revealed confusion among staff about responsibility for vaccine education, with the ADON assuming the DON was responsible and the Regional Nurse believing it was unnecessary post-Public Health Emergency. The DON was unsure if education was provided, indicating a systemic issue in managing COVID-19 vaccination protocols.
A facility failed to provide written notification of a hospital transfer to a resident and the Ombudsman. The resident, who had moderate cognitive impairment, was sent to the hospital after a fall. Interviews revealed that the resident was unaware of any written notification, and the DON confirmed that notifications should have been issued to both the resident and the Ombudsman.
A facility failed to provide a written bed hold policy notification to a resident with moderate cognitive impairment who was transferred to the hospital after a fall. The resident was unaware of receiving such notification, and the LPN confirmed the requirement for written provision. The DON acknowledged the oversight.
A facility failed to complete an annual MDS for a resident, as required by federal guidelines. The MDS Coordinator, who took over after the due date, noted that the previous program lacked notifications for overdue assessments. The facility switched to a new system that provided due dates, but this change occurred after the MDS was already overdue. The DON confirmed the need for timely MDS completion.
A facility failed to complete MDS assessments for a resident at the required intervals. The resident's third quarterly MDS was completed one month late, and the annual MDS was not completed. The MDS Coordinator noted that the previous software did not provide overdue notifications, contributing to the oversight. The facility switched to a new program, but the resident's MDS was already overdue.
A resident with dysphagia and gastrostomy status was not accurately assessed for dental issues, despite having broken teeth and reporting daily pain. The MDS did not document these concerns, and interviews revealed that the MDS nurse and DON were unaware of the resident's dental condition, indicating a failure in the assessment process.
The facility failed to personalize care plans for two residents, leading to deficiencies in communication and dental care. One resident's communication care plan lacked specific interventions despite their preference for Spanish and moderate cognitive impairment. Staff relied on family for translation and used basic Spanish and gestures. Another resident with dysphagia and broken teeth had no dental care plan, and staff were unaware of their dental issues, despite the resident reporting daily pain. These deficiencies highlight inadequate care planning.
The facility failed to ensure the activities program was directed by a qualified professional. The current Activities Director (AD) lacked the necessary qualifications, including two years of college, relevant experience, or state-approved training. The Administrator acknowledged the deficiency, and an attempt to interview the AD was unsuccessful. The facility's policy for the AD was requested but not provided.
A resident with dysphagia and broken teeth did not receive necessary dental care, despite expressing daily pain. The facility staff, including the SSD, LPN, CNAs, and DON, were unaware of the resident's dental issues, and the resident was not seen by the dentist during the last visit. There was no documentation of a dental consent form being provided upon admission.
The facility did not post complete daily nurse staffing information, omitting total actual hours worked for RNs, LPNs, CMTs, CNAs, and NAs. Observations showed missing data on staffing sheets near the nurse's station and no postings in the Behavioral Unit. Staff interviews confirmed the incomplete postings.
A resident with impaired cognition was injured in a dining room altercation when another resident, known for verbal symptoms, hit them on the head with a ringed hand. The incident was triggered by the victim flipping another resident's hat. No staff witnessed the event, and the injury was discovered by a CNA during a shower. The aggressor admitted to the inappropriate behavior.
Failure to Maintain Supervision on Behavioral Health Unit Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate staffing coverage and supervision on the secure behavioral locked unit, resulting in an altercation between two residents. On the evening in question, a Certified Medication Technician (CMT) left the behavioral unit unsupervised to retrieve printed Medication Administration Records (MARs) due to an internet outage, leaving no staff present on the unit. During this period, two residents engaged in a verbal and physical altercation in the hallway, with one resident striking the other in the upper arm after a dispute over delayed medication administration. The residents involved had significant behavioral health diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. One resident was moderately cognitively impaired, while the other was cognitively intact but had a history of agitation when routines or medication schedules were disrupted. The incident occurred after one resident became upset about not receiving medication on time, leading to a confrontation and subsequent physical contact. Interviews with staff and residents confirmed that the behavioral unit was left without staff supervision at the time of the incident. Multiple staff members, including the CMT, LPNs, CNAs, the Administrator, and the DON, acknowledged that the behavioral unit should never be left unattended and that at least one staff member should always be present. The facility was unable to provide a staffing policy at the time of the survey exit.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to prevent verbal and physical abuse between two residents on the behavioral health locked unit. On the evening of 12/26/25, two residents with significant psychiatric diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression, engaged in a verbal and physical altercation. The incident occurred after one resident became upset about not receiving medication due to a facility internet outage, which delayed the medication pass. The two residents exchanged words, escalated to yelling, and then one resident struck the other in the upper arm. At the time of the incident, there were no staff members present on the locked behavioral unit. The Certified Medication Technician (CMT) assigned to the unit had left to print medication administration records necessary for the medication pass, as the internet was down. Multiple resident interviews confirmed that staff were not present during the altercation, and one resident had to bang on the locked doors to alert staff to the fight. Staff interviews corroborated that the unit was unsupervised during the event, and the administrator acknowledged that staff supervision was expected at all times on the unit. The facility's own Abuse and Neglect Policy states that residents have the right to be free from abuse and that the facility will actively protect residents from such incidents. The lack of staff supervision on the locked behavioral unit directly contributed to the occurrence of resident-to-resident abuse, as there was no immediate intervention or oversight to prevent or de-escalate the situation.
Failure to Provide Private Telephone Access for Residents
Penalty
Summary
The facility failed to ensure that residents on the locked unit had the opportunity to make and receive phone calls without being overheard, as required by their own policy. Residents who did not possess their own phones were required to use the telephone located in the nurses' office, where privacy could not be guaranteed. Staff were typically present in the office during resident calls, and the phone's location and short cord length further limited privacy. Residents reported that staff rarely offered privacy, and even when requested, staff would leave the door ajar to monitor the resident, allowing conversations to be overheard in the hallway. Multiple residents on the locked unit, including individuals with schizoaffective disorder, ADHD, and autistic disorder, expressed dissatisfaction with the lack of privacy during phone calls. These residents indicated that they would prefer to have private conversations but were not provided with a means to do so. The facility previously had a portable phone that allowed residents to make private calls, but this was discontinued about a year prior when a new phone system was installed. Since then, no alternative arrangements for private phone access had been made for residents without personal phones. Staff interviews confirmed that the only phone available for resident use was in the nurses' office and that staff presence was standard unless privacy was specifically requested. Even then, privacy was limited due to the need to keep the door ajar for supervision. There were also informal restrictions on when residents could use the phone, depending on staff availability, and some staff imposed time limits on calls. The facility's administration and nursing leadership acknowledged these practices and the absence of a portable phone, but no clarification or alternative had been provided to ensure residents' right to private communication.
Improper Disposal of Medical Records Breaches Resident Confidentiality
Penalty
Summary
The facility failed to maintain personal privacy and confidentiality of residents' personal and medical records by disposing of protected health information (PHI) in a public dumpster. This incident involved 136 residents, with medical records dating from 2008 to 2018 being placed in closed boxes and discarded off-site at a laundry building. The boxes were labeled with residents' names and years, making the information easily identifiable. The maintenance director was responsible for placing the records in the dumpster, and the administrator was notified of the breach after the records were discovered. Interviews revealed that the maintenance director was not aware of HIPAA regulations at the time of the incident and mistakenly disposed of the records in the dumpster. Other staff members, including an LPN and a housekeeper, demonstrated awareness of HIPAA requirements and stated that protected information should be placed in designated shred boxes or given to a charge nurse for proper disposal. The facility's policies required that PHI be managed and protected to prevent unauthorized release or disclosure, but these procedures were not followed in this instance, resulting in a breach of confidentiality.
Infection Control and EBP Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, specifically for Legionella and other water-borne pathogens. The facility's Legionella Water Management Plan was incomplete and outdated, with numerous sections left blank, including risk assessments, control measures, and documentation of maintenance activities. The facility lacked a Director of Maintenance to implement the program, and the Administrator acknowledged the absence of a responsible person for the Legionella program. The facility also failed to ensure that all residents received a two-step tuberculosis (TB) skin test upon admission. Several residents' medical records lacked documentation of the TB skin test, and there was no guidance in the facility's policy for completing the test. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed inconsistencies in the administration and documentation of the TB skin tests. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds or indwelling medical devices. Observations and interviews indicated that staff were not aware of which residents required EBP, and there were no signs or isolation carts to indicate the need for EBP. Staff interviews revealed a lack of understanding and training on EBP, and the Infection Preventionist was not present to ensure compliance.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and well-being of residents, as evidenced by the lack of activities for three sampled residents. Resident #19, who was cognitively intact, expressed a desire to go outside and engage in activities like playing cards and working with models. However, the resident's participation logs showed limited engagement, primarily in coffee club and bingo, with no activities scheduled on weekends. The resident reported a lack of activities on weekends and mentioned that the Activity Director was unsure of what to plan for the residents. Resident #23, who was moderately cognitively impaired, also experienced a lack of activities, particularly on weekends. The resident's participation logs indicated sporadic involvement in coffee club and bingo, with no logs available for September. The resident expressed dissatisfaction with the lack of activities and noted that due to behavior issues among some residents, they were no longer allowed to participate in activities with others. Similarly, Resident #36, who was cognitively intact and valued listening to music and going outside, reported a lack of activities and an absence of a current activities calendar. Observations from 9/9/24 to 9/11/24 confirmed the absence of activities on the unit. Interviews with staff, including CNAs and a CMT, revealed that activities were not conducted regularly, especially on weekends, and that the Activities Director was out due to illness. The Director of Nursing was unaware of the lack of activities on weekends and who was responsible for conducting them in the absence of the Activities Director. The deficiency in providing a comprehensive activities program had the potential to affect all residents in the facility.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was moderately cognitively impaired, had a care plan that included approaches for managing mental distress related to PTSD. However, observations and interviews revealed that staff were not fully aware of the resident's needs or specific triggers associated with PTSD. The resident exhibited behaviors such as pacing and restlessness, and sometimes expressed feelings of claustrophobia while smoking outside. Interviews with staff, including CNAs and LPNs, indicated a lack of awareness and training regarding the resident's PTSD diagnosis and associated care needs. Some staff were unsure of the resident's specific triggers and had not received recent training on PTSD. The MDS coordinator and the Director of Nursing also expressed a lack of knowledge about the resident's PTSD history and the frequency of trauma-informed care training provided to staff. The facility's Trauma Informed Care Policy outlined the need for staff training and the inclusion of trauma-informed care in the Quality Assurance Improvement Plan. However, the administrator and the Regional Nurse Consultant were unable to provide documentation of recent training sessions, indicating a gap in the implementation of the policy. This lack of training and awareness among staff contributed to the deficiency in providing appropriate trauma-informed care for the resident.
Narcotic Documentation and Count Discrepancies
Penalty
Summary
The facility failed to ensure accurate documentation of narcotic pain medication on the Medication Administration Record (MAR) and the narcotic count log for four residents. This deficiency was identified through interviews and record reviews, revealing discrepancies in the documentation and administration of narcotic medications. For instance, Resident #8's records showed that 102 Oxycodone tablets were documented as administered, but only 51 tablets were accounted for in the narcotic log, indicating a significant discrepancy. Additionally, there were instances where two tablets were signed out simultaneously, contrary to the physician's order for one tablet. Further investigation into Resident #23's records showed that 12 Hydrocodone tablets were unaccounted for, as the narcotic log and MAR did not match. Similarly, Resident #19's records indicated that 53 Norco tablets were documented as administered, but only 47 were signed out, leaving six tablets unaccounted for. Resident #36's records also showed discrepancies, with several Oxycodone tablets unaccounted for across different months. These inconsistencies highlight a failure in the facility's medication management and documentation processes. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that narcotic counts were not consistently conducted at shift changes, and there were numerous instances of missing signatures on narcotic count sheets. Staff admitted to not always counting liquid narcotics stored in the refrigerator, assuming they were full and unopened. The DON acknowledged responsibility for ensuring accurate narcotic counts and documentation but noted that there were many blanks on the narcotic sheets, indicating lapses in the facility's procedures.
Failure to Document and Educate on Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and education regarding pneumonia vaccinations for five residents upon their admission. The facility's policy, dated March 2022, mandates that all residents be offered pneumococcal vaccines and be assessed for eligibility prior to or upon admission. Additionally, residents or their representatives should receive education about the benefits, risks, and potential side effects of the vaccine. However, for Residents #15, #32, #36, #37, and #342, there was no documentation of their pneumonia vaccination status, no record of them being offered the vaccine, and no evidence that they were provided with the necessary educational information upon admission. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring that pneumonia education is provided upon admission. The Assistant Director of Nursing (ADON) was unsure who was responsible for this task, while the Director of Nursing (DON) acknowledged that pneumonia education and vaccination records should be documented in the resident's medical record upon admission. The DON also expressed uncertainty about whether the residents received the required education regarding pneumonia vaccines. This lack of documentation and clarity in roles contributed to the deficiency identified by the surveyors.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure the provision and documentation of education regarding the COVID-19 vaccine for both residents and staff. Specifically, five residents and five staff members were not provided with education about the benefits, risks, and potential side effects of the COVID-19 vaccine upon admission or hire. The facility's policy requires that each resident be offered the vaccine unless contraindicated and that education be provided in an understandable format. However, there was no documentation in the medical records of the sampled residents or the employment records of the sampled staff indicating that this education was provided. Interviews with facility staff revealed a lack of clarity and responsibility regarding the provision of COVID-19 vaccine education. The Assistant Director of Nursing (ADON) stated that they did not provide the education and assumed the Director of Nursing (DON) was responsible. The Regional Nurse expressed the belief that the facility was not required to obtain vaccination status or provide education since the Public Health Emergency had ended. The DON acknowledged that vaccination records should be maintained but was unsure if education was provided to residents and staff. The deficiency highlights a breakdown in the facility's processes for ensuring compliance with its own policies on COVID-19 vaccination education and documentation. The lack of documentation and education for both residents and staff indicates a systemic issue in the facility's approach to managing COVID-19 vaccination protocols. This failure to adhere to established policies could potentially impact the health and safety of both residents and staff.
Failure to Notify Resident and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of a hospital transfer/discharge for one resident, as well as to the Ombudsman, when the resident was transferred to the hospital. The incident involved a resident who was found on the floor and complained of pain in the right hip. The facility's physician was notified, and orders were given to send the resident to the emergency room. However, there was no documentation in the resident's paper chart or electronic health record indicating that a transfer/discharge notification was provided to the resident or the Ombudsman. Interviews conducted during the investigation revealed that the resident was unaware of receiving any written notification regarding the hospital transfer. A Licensed Practical Nurse (LPN) mentioned that the physician and family were typically notified in writing when residents were transported out of the facility, and that the Ombudsman must also be notified. The Director of Nursing (DON) confirmed that transfer/discharge notifications should have been issued to the resident and the Ombudsman, and that family and residents should be notified in writing with the reason for the transfer.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its Bed Hold policy to a resident who was transferred to the hospital. This deficiency was identified for one resident out of a sample of 13, in a facility with a census of 40 residents. The resident, who had moderate cognitive impairment, was sent to the emergency room following a fall and subsequent complaint of hip pain. A review of the resident's nurse progress notes and health records showed no evidence that the bed hold policy was issued. During interviews, the resident expressed unawareness of receiving any written notification regarding bed hold, and the LPN confirmed that bed hold policies must be provided in writing. The DON acknowledged that a bed hold policy should have been issued when residents are sent to the hospital.
Failure to Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) for a resident, as required by federal guidelines. The resident's admission MDS was completed, but the subsequent annual MDS, which was due within 366 days, was not completed. This oversight was identified during a review of the resident's assessments, which showed that the annual MDS was due but not completed. The facility's policy indicated that the assessment coordinator or designee was responsible for ensuring timely submission of assessments according to federal and state guidelines. The MDS Coordinator, who assumed the role after the annual MDS was due, stated that the previous program used for MDS completion did not provide notifications for past due assessments. The facility switched to a new program, which provided a list of residents and their MDS due dates, but this transition occurred after the annual MDS was already overdue. The Director of Nursing confirmed that MDS assessments should be completed timely, following the guidelines in the Resident Assessment Instrument Manual.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for a resident at the required intervals, as mandated by federal guidelines. The resident's admission MDS was completed on January 27, 2023, followed by the first and second quarterly MDS on April 24, 2023, and July 22, 2023, respectively. However, the third quarterly MDS, due on October 22, 2023, was not completed until November 2, 2023, making it one month late. Furthermore, the annual MDS due on January 28, 2024, was not completed, and no assessments were conducted after April 19, 2024. The MDS Coordinator, who assumed the role in February 2024, indicated that the previous software used for MDS completion did not provide notifications for overdue assessments, which contributed to the oversight. The facility transitioned to a new program on August 19, 2024, which provided a list of due assessments, but by then, the resident's MDS was already overdue. The Director of Nursing acknowledged that the MDS should be completed timely, in accordance with the Resident Assessment Instrument (RAI) manual.
Failure to Accurately Assess Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess a resident's oral and dental status, specifically regarding broken natural teeth and mouth pain. The resident, who had been admitted with diagnoses including dysphagia and gastrostomy status, was noted in the Admission Nursing Evaluation to have broken teeth. However, the Minimum Data Set (MDS) completed for the resident did not document any dental concerns, such as broken or missing teeth, or mouth or facial pain. This discrepancy indicates a failure in the assessment process, as the MDS did not reflect the resident's actual condition as observed and reported. Interviews with the MDS nurse and the Director of Nursing (DON) revealed that neither was aware of the resident's broken teeth, despite the resident expressing daily concerns about dental pain. The MDS nurse expected the MDS to accurately reflect the resident's condition based on nursing assessments, yet failed to capture the necessary documentation from the clinical chart. The DON also expected the MDS to be accurate and for the MDS nurse to conduct thorough assessments, highlighting a gap in communication and assessment practices within the facility.
Deficiencies in Communication and Dental Care Plans
Penalty
Summary
The facility failed to personalize a communication care plan for two residents, leading to deficiencies in their care. For the first resident, the admission Minimum Data Set (MDS) indicated that Spanish was their preferred language, and they were moderately cognitively impaired. Despite this, the communication care plan lacked specific interventions and details on how to assist the resident with communication. Observations showed the resident communicated in Spanish and used a translator application, while staff interviews revealed reliance on family members for translation and the use of hand gestures and basic Spanish by some staff. The MDS Coordinator acknowledged the care plan should have included specific communication interventions. The second resident had a history of dysphagia and gastrostomy status, with broken teeth noted in the Admission Nursing Evaluation. However, the MDS did not document any dental concerns, and the care plan lacked a dental care plan. Observations confirmed the resident had multiple missing and broken teeth, and the resident reported daily pain and concerns about their teeth. Interviews with staff, including the LPN, Social Services Designee, CNAs, and the MDS nurse, revealed a lack of awareness of the resident's dental issues. The Director of Nursing also confirmed the expectation that the care plan should reflect dental concerns. These deficiencies highlight the facility's failure to ensure comprehensive and personalized care plans for residents, particularly in addressing communication needs and dental health. The lack of specific interventions and awareness among staff contributed to the inadequate care planning for these residents.
Unqualified Activities Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by their own job description and state regulations. The facility's policy for the Activities Director (AD) was requested but not provided. The job description for the AD position specified that the individual must possess at least two years of college, be a qualified therapeutic recreation specialist, or have relevant experience or training. However, the current AD, who has been in the position for three months, did not meet these qualifications. The AD was a Certified Medication Technician (CMT) and a Certified Nurse Assistant (CNA) with a General Education Development (GED) and one year of college, but lacked the necessary experience or state-approved training. During an interview, the Administrator acknowledged that the AD did not have the required qualifications and needed to become qualified. An attempt to interview the AD was made, but the call was not returned. The facility census at the time was 40 residents, indicating that the deficiency could potentially impact a significant number of individuals. The lack of a qualified professional to direct the activities program represents a failure to comply with regulatory standards and the facility's own policies.
Failure to Provide Dental Care for Resident with Broken Teeth
Penalty
Summary
The facility failed to provide routine and emergency dental services to a resident, identified as Resident #37, who had multiple missing and broken teeth. The resident, who was admitted with a diagnosis of dysphagia, expressed daily pain and concern regarding their dental condition. Despite having an order for a dental consult and treatment, the resident was not seen by the dentist during the last visit on 7/25/24, and there was no documentation of a dental consent form being provided upon admission. Interviews with facility staff, including the Social Service Director (SSD), Licensed Practical Nurse (LPN), Certified Nurses Aides (CNAs), and the Director of Nursing (DON), revealed a lack of awareness regarding the resident's dental issues. The SSD was responsible for obtaining dental consents and scheduling appointments but was unaware of the resident's broken teeth and the last provision of dental services. The CNAs and MDS nurse also did not recognize the resident's dental needs, and the resident had not reported the need for dental care to them.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted correctly at the beginning of each shift, as required by federal regulations. The posted staffing sheets from 9/5/24 through 9/11/24 did not include the total actual hours worked for each discipline, such as RNs, LPNs, CMTs, CNAs, and NAs. Observations on multiple dates confirmed that the staffing sheets near the front nurse's station lacked this information, and no staffing sheets were posted in the locked Behavioral Unit. Interviews with staff, including a CNA, an LPN, and the Director of Nursing, revealed that the daily staffing sheet was only posted near the main nursing station and not in the Behavioral Unit. The Director of Nursing acknowledged that the form used by the facility did not show a total for the actual hours worked per discipline and confirmed that the staffing sheet should also be posted in the locked Behavioral Unit.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents. On the morning of April 3, 2024, in the dining room, one resident hit another on the head, causing an abrasion. The aggressor was wearing a ring, which contributed to the injury. The incident was triggered when the victim flipped the hat of another resident, which agitated the aggressor. The victim of the altercation had a history of severely impaired cognition due to Alzheimer's Disease and other medical conditions, while the aggressor was cognitively intact but had a history of verbal symptoms towards others. The aggressor admitted to hitting the victim and acknowledged that it was inappropriate behavior. There were no staff witnesses to the incident, and it was reported by a CNA who noticed the abrasion during a shower. Interviews with other residents and staff revealed that the victim had a history of behaviors that could provoke others, such as teasing and stealing. The aggressor was known to be easily annoyed and had a tendency to meddle. Despite these known behaviors, the facility did not prevent the altercation, resulting in a failure to protect the resident from abuse.
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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