Clearview Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sikeston, Missouri.
- Location
- 430 Salcedo Road, Sikeston, Missouri 63801
- CMS Provider Number
- 265614
- Inspections on file
- 15
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Clearview Nursing Center during CMS and state inspections, most recent first.
The facility failed to follow infection control practices during wound care for two residents, catheter care for one resident, and g-tube medication administration for one resident. Staff entered rooms without EBP signage or PPE available outside the door, and LPNs and CNAs performed care using gloves only or no gown when gowns were expected for residents with wounds or indwelling devices. The laundry area also had dirty laundry at the entrance and clean linen carts in the back with no physical separation, and clean and soiled laundry used the same door for entry and exit.
Failure to respect resident dignity and provide timely assistance: A resident repeatedly asked for coffee but was ignored by staff and then told in a loud, stern voice that the kitchen was closed without any alternative offered. Another resident was left in bed with the call light and water out of reach and missed lunch until later, and two LPNs performed wound care with the curtain open and the door not closed, exposing the resident's bare backside to the hallway.
Failure to address side rail use and entrapment risk in care plans. Four residents were repeatedly observed with half side rails upright, but their care plans did not address the rails or the related fall history where applicable. One resident with impaired cognition said the rails were already on the bed and were used to help turn in bed, while another resident had dementia and recent unwitnessed falls. The DON, Administrator, and MDS Coordinator stated falls and side rail use should be addressed on the care plan.
Failure to assess, document, and obtain informed consent for side rail use was identified for four residents. Residents had diagnoses including fracture, COPD, autism, seizures, dementia, falls, spinal stenosis, MS, HF, and acute respiratory failure with hypoxia, with cognition ranging from intact to severely impaired and two residents having legal guardians. Observations repeatedly showed both half side rails upright, while the DON and Administrator stated assessments should occur before side rails are placed and then quarterly.
Failure to post daily nurse staffing in a prominent location: The facility posted the staffing sheet only on the east end near the nurses' station and did not post it at the main entrance or west end where it was readily accessible to residents and visitors. A CNA, MDS Coordinator, LPN, DON, and Administrator all stated the east end was the only posting location used, and no policy on nurse staff posting was provided.
The facility failed to regularly inspect bed frames, mattresses, and side rails for four residents with diagnoses including fracture, COPD, autism, seizures, dementia, falls, spinal stenosis, MS, heart failure, and acute respiratory failure with hypoxia. Observations showed both half side rails upright and moving with minimal effort, and the medical records showed no maintenance inspection for the side rails. The DON said maintenance had not completed any inspections, the maintenance staff said the rails were placed when nursing requested and had not been inspected, and the Administrator expected side rail inspections at least quarterly.
Call lights were not kept within reach for multiple residents, including residents observed in bed, in a Geri-chair, and in a wheelchair. Surveyors found call lights on the floor, on a nightstand, in a trash can, attached to a privacy curtain, or hanging from a wall frame at the foot of the bed, all out of reach. The facility did not provide a call light policy, and the Administrator, CNA, LPN, and DON all stated call lights should always be within residents’ reach.
Failure to Provide Required CNA Annual In-Service and Competency Training: The facility failed to ensure two CNAs received at least 12 hours of annual in-service education and the required annual competency training in dementia care, abuse, and neglect prevention. Records showed both CNAs attended only a limited number of in-services, neither attended the required competency topics, and the monthly in-service sheets did not document the time for each session. The DON stated CNAs should have 12 hours of annual in-services and that abuse, neglect, and dementia training should be included.
The facility failed to address grievances and maintain inventory documentation for two residents. Despite the grievance protocol requiring documentation and follow-up, the grievance log was empty, and no grievances were initiated for missing items reported by the residents. Staff interviews revealed a lack of awareness and action, with the SSD admitting to not completing grievances and the Administrator unsure about the grievance policy.
The facility failed to obtain physician orders for code status for two residents and inconsistently documented another resident's code status. A resident's face sheet indicated DNR, but the POS showed Full Code. Interviews revealed that the SSD was responsible for ensuring code status at admission, but inconsistencies in documentation and obtaining physician orders led to deficiencies.
The facility failed to maintain a safe, clean, and homelike environment, with observations of worn furniture, peeling wallpaper, and cluttered areas. Staff interviews revealed a lack of communication and documentation regarding maintenance issues, contributing to the deficiency.
The facility inaccurately coded the MDS for two residents regarding anticoagulant therapy. One resident's MDS did not reflect their anticoagulant use, despite medical records indicating otherwise. Another resident's MDS incorrectly showed anticoagulant use, while records only indicated aspirin use. Interviews with staff confirmed the need for accurate MDS assessments.
The facility failed to conduct the required PASARR screening for two residents upon admission. One resident with dementia and PTSD did not have the necessary screening documented, while another with bipolar disorder and schizophrenia had their screening rejected due to missing psychiatric documentation. The Social Service Director and Administrator acknowledged these oversights.
A facility failed to monitor and address a resident's significant weight loss, resulting in a 10.38% decrease over six months. The facility's policy required oversight by a weight champion, but there was no effective monitoring or intervention. The resident's care plan lacked specific interventions for weight loss, and recommendations for a multivitamin and weekly weights were not followed. Interviews revealed the absence of meetings to discuss residents' weights, and the resident's family had to bring the issue to the facility's attention.
The facility reported a medication error rate of 8.11% due to improper administration of insulin and ondansetron. An RN failed to prime insulin pens for two residents, and a CMT incorrectly administered ondansetron to another resident. Interviews revealed a misunderstanding about insulin pen priming requirements.
The facility failed to implement Enhanced Barrier Precautions during wound care for a resident and did not use proper hand hygiene during blood sugar testing for four residents. An RN did not follow the facility's policy for EBP, failing to use gowns and gloves appropriately and neglecting hand hygiene. Additionally, the RN consistently did not perform hand hygiene before and after glove use during blood sugar testing, indicating a systemic issue with infection control practices.
The facility failed to provide the required twelve hours of annual in-service training for CNAs, specifically in dementia care and abuse prevention. Two CNAs did not receive the necessary training, with records showing incomplete attendance and missing documentation of time durations. The facility lacked a policy for nurse aide in-service training, and both the DON and Administrator acknowledged the deficiency.
Infection Control Lapses During Resident Care and Laundry Handling
Penalty
Summary
The facility failed to ensure staff used acceptable infection control procedures and practices during wound care for two residents, catheter care for one resident, and g-tube medication administration for one resident. The facility’s policy on Enhanced Barrier Precautions (EBP), revised March 2024, stated that residents with indwelling medical devices, including urinary catheters and feeding tubes, and residents with wounds required EBP, including use of gowns and gloves for high-contact care activities such as wound care and care of indwelling devices. The facility also did not provide a policy regarding infection control practices in laundry services. During observation, Resident #6’s medication administration via g-tube was performed without EBP signage on the door, without PPE available outside the room, and without the LPN putting on a gown. During wound care for Resident #55, there was no EBP signage or PPE outside the room, and two LPNs gathered supplies at the door, entered without hand hygiene, gloves, or gowns, and one LPN performed the wound care. During wound care for Resident #1, there was no EBP signage or PPE outside the room, and an LPN entered after hand hygiene and gloves only, without a gown, and provided wound care. For Resident #4’s catheter care, there was no EBP signage or PPE outside the room, and two CNAs entered after hand hygiene and gloves only, without gowns, and one CNA provided catheter care. In interviews, staff gave inconsistent responses about EBP and PPE use, including uncertainty about why certain residents required supplies and whether gowns were needed for residents with catheters, wounds, or g-tubes. In the laundry room, dirty laundry barrels were located at the entry, clean linen carts were in the back, and there was no physical separation between dirty and clean laundry areas; all clean laundry and linen carts had to pass the soiled area to exit the building. Staff stated the clean linens exited through the same door the dirty laundry entered, and the IP and Administrator acknowledged the laundry room had only one entrance/exit.
Failure to Respect Resident Dignity and Provide Timely Assistance
Penalty
Summary
The facility failed to ensure staff maintained or enhanced the quality of life for two residents and failed to maintain the dignity of one resident when care and interactions were not handled appropriately. One resident sat in the hall and asked two different staff members for a cup of coffee, but neither staff member acknowledged the request. When the resident asked a CNA again, the CNA responded in a loud and stern voice that the kitchen was closed and walked past without offering another option or redirecting the resident. The CNA later stated staff tried not to give the resident coffee because it caused anxiety and made the resident want to get out of bed, while the DON stated staff should acknowledge requests and offer another drink or redirect the resident. Another resident was observed lying in bed with the call light and water out of reach and stated he/she had not had lunch yet and was hungry. The resident was later transferred to a wheelchair and then sat at the dining room table, asked for water, and ate lunch. An LPN stated the resident had refused to get up earlier and was left alone because he/she was on hospice, and that if a tray was put back the LPN would have to stay in the dining room later and would be behind in duties. In a separate observation, two LPNs provided wound care to a resident without the privacy curtain pulled and/or the door closed, leaving the resident's bare backside exposed to the hallway while two unknown persons passed by the room. The LPNs stated they normally closed the door or pulled the curtain during wound care, and the DON stated privacy should be provided during wound care or treatments.
Failure to Address Side Rail Use and Entrapment Risk in Care Plans
Penalty
Summary
The facility failed to assess residents for entrapment risk, review the possible risks and benefits of side rails before installation or use, and obtain informed consent for side rail use for four sampled residents. The deficiency was identified during observation, interview, and record review in a facility with a census of 62. The facility policy stated it would use the current CMS MDS RAI Manual and applicable federal guidelines for MDS completion, CAAs, and resident care planning. Resident #1 had diagnoses including a left leg fracture, pain, muscle weakness, COPD, and moderately impaired cognition. The resident was observed multiple times with both half side rails upright and stated the rails were used to help turn side to side in bed; the rails were already on the bed upon admission. The care plan revised on 02/26/26 did not address the half side rail use. Resident #6 had diagnoses including autistic disorder, pervasive developmental disorder, seizures, and unspecified intellectual disabilities, with cognition severely impaired; the resident was repeatedly observed with both half side rails upright, and the care plan dated 01/09/26 did not address side rail use. Resident #52 had diagnoses including dementia, history of falls, UTI, and hypertension, with unwitnessed falls on 01/15/26 and 01/21/26; the resident was repeatedly observed with both side rails upright and a fall mat on the floor beside the bed, and the revised care plan did not address side rail use. Resident #55 had diagnoses including cervical spinal stenosis, multiple sclerosis, heart failure, and acute respiratory failure with hypoxia, with intact cognition; the resident was repeatedly observed with both half side rails upright, and the revised care plan did not address side rail use. The DON, Administrator, and MDS Coordinator each stated they would expect falls and side rail use to be addressed on the care plan.
Failure to Assess and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to assess residents for the risk of entrapment, review the risks and benefits of side rails with the resident or representative, obtain informed consent, and document a side rail assessment before use for four sampled residents. The report states the facility also did not provide a side rail assessment policy. Resident #1 had diagnoses including a left leg fracture, pain, muscle weakness, and COPD, with moderately impaired cognition, and the record contained no documentation of a side rail assessment or informed consent. Observations showed both half side rails in the upright position on multiple occasions, and the resident stated the rails were used to help turn side to side in bed and were already on the bed upon admission. Resident #6 had autistic disorder, pervasive developmental disorder, seizures, unspecified intellectual disabilities, severely impaired cognition, and a legal guardian, with no documentation of a side rail assessment or informed consent; observations repeatedly showed both half side rails upright and the resident lying in bed with the rails up. Resident #52 had dementia, a history of falls, UTI, hypertension, severely impaired cognition, and a legal guardian, with no documentation of a side rail assessment or informed consent; observations showed the resident lying in bed with both half side rails upright. Resident #55 had spinal stenosis of the cervical region, multiple sclerosis, heart failure, and acute respiratory failure with hypoxia, had intact cognition, and also had no documentation of a side rail assessment or informed consent; observations showed both half side rails upright, and the resident stated he/she could not physically use the side rails at that time but had used them in the past. The DON stated side rail assessments were supposed to be completed initially and quarterly, and the Administrator stated an assessment should be completed before side rails were placed on a resident's bed and then assessed quarterly.
Failure to Post Daily Nurse Staffing in a Prominent Location
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for four out of four days. The facility census was 62, and the report states that no policy on nurse staff posting was provided. Observations on 03/02/26, 03/03/26, 03/04/26, and 03/05/26 showed the daily nurse staffing posted only on the east end of the facility near the nurses' station. The staffing information was not posted at the main entrance or at the west end area of the facility, and it was not posted in a prominent place accessible to all residents and visitors. During interviews, a CNA, the MDS Coordinator, an LPN, the DON, and the Administrator all stated that the staffing sheet had always been posted on the east end near the nurses' station, and that this was the only location used for posting. The MDS Coordinator and LPN said the charge nurse on the east end usually completed and posted the daily staffing sheet each morning.
Failure to Inspect Bed Side Rails
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and side rails for four residents: one resident with a left leg fracture, pain, muscle weakness, and COPD; one resident with autistic disorder, pervasive developmental disorder, seizures, and unspecified intellectual disabilities; one resident with dementia, a history of falls, UTI, and hypertension; and one resident with cervical spinal stenosis, multiple sclerosis, heart failure, and acute respiratory failure with hypoxia. For each of these residents, the medical record showed no maintenance inspection for the side rail, while observations on multiple dates showed both half side rails in the upright position on the residents’ beds and moving with minimal effort. The facility did not provide a side rail inspection policy. During interview, the DON stated that if side rails were on a resident’s bed, maintenance should inspect them at least monthly, and later said maintenance had not completed any inspections on the side rails. The maintenance staff said side rails were placed on residents’ beds when nursing requested it and that if nothing was entered in the maintenance log, he/she would not know about them until notified; the staff also stated the side rails had not been inspected. The Administrator said he expected staff to inspect side rails on resident beds at least quarterly.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
Call lights were not kept within reach for multiple residents, including Residents #5, #6, #52, #54, #67, and Resident #12 outside the sample. During repeated observations, Resident #67 was seen in bed and later in a Geri-chair with the call light lying on the floor out of reach. Resident #52 was observed in bed with the call light on the floor out of reach. Resident #5 was observed in bed with the call light on the floor out of reach and later in a Geri-chair with the call light attached to a privacy curtain at the foot of the bed, out of reach. Resident #54 was observed in bed with the call light on the nightstand out of reach and later inside a trash can on the floor beside the nightstand, also out of reach. Resident #6 was observed in bed with the call light attached to a privacy curtain at the foot of the bed, out of reach. Resident #12 was observed in bed and later in a wheelchair beside the bed with the call light hanging from a metal frame attached to the wall at the foot of the bed, out of reach. The facility did not provide a call light policy. During interviews, the Administrator, CNA A, LPN B, and the DON all stated that call lights should be within residents' reach, and the DON said staff should check periodically and when entering and exiting rooms to ensure call lights were within reach.
Failure to Provide Required CNA Annual In-Service and Competency Training
Penalty
Summary
The facility failed to ensure that nurse aides received at least 12 hours of annual in-service education and failed to provide required annual competency training in Dementia Care, Abuse, and Neglect prevention for two sampled CNAs, CNA C and CNA D, out of two reviewed. The facility census was 62. The facility did not provide a nurse aide in-service education policy. Its Facility Assessment, revised 01/21/26, stated that CNA training at hire and annually thereafter must be sufficient to ensure continuing competence, be no less than 12 hours per year, and include dementia management training and resident abuse prevention. Review of in-service records showed CNA C, hired 12/12/24, attended three in-services during the review period but did not attend the annual competency in-service on Dementia Care, Abuse, and Neglect. The monthly in-service sheets did not document the time for each in-service, and the facility did not provide CNA C with the required 12 hours of in-service education for December 2024 through December 2025. CNA D, hired 11/01/24, attended five in-services but also did not attend the annual competency in-service on Dementia Care, Abuse, and Neglect. The monthly in-service sheets again lacked times for each in-service, and the facility did not provide CNA D with the required 12 hours of in-service education for November 2024 through November 2025. The DON stated CNAs should have 12 hours of annual in-services and that abuse, neglect, and dementia training should be included, with a time duration documented for each in-service.
Failure to Address Resident Grievances and Maintain Inventory Documentation
Penalty
Summary
The facility failed to respond or act upon grievances and did not maintain documentation of inventory for two residents. The facility's grievance protocol, which was undated, required a written record of each resident and family concern, with the Social Service Director (SSD) responsible for the program and the Administrator ultimately responsible for its implementation. However, the facility's grievance log was found to be empty, indicating a lack of documentation of any reported grievances. Resident #48 reported missing an electronic tablet and a cell phone, and although the SSD and Administrator were made aware, no grievance was initiated. Similarly, Resident #23 reported missing a cereal cup full of quarters and two electronic tablets, but no grievance was filed, and the SSD did not recall the missing tablet. Interviews with staff revealed a lack of awareness and action regarding the missing items. The SSD admitted to not initiating or completing grievances and acknowledged the absence of inventory sheets for the residents. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) were aware of the missing items and would notify the charge nurse or Director of Nursing (DON) when items were reported missing. The DON confirmed that an investigation should be started immediately when items are reported missing, but the Administrator was unsure about the grievance policy and had never replaced items for residents in the past.
Failure to Document and Obtain Physician Orders for Code Status
Penalty
Summary
The facility failed to obtain a physician's order for code status for two residents and did not consistently document a resident's code status. Resident #14 was admitted with a Full Code status indicated on the face sheet and the spine of the hard chart, but there was no physician's order for the code status on the Physician Order Sheet (POS). Similarly, Resident #38's medical record showed a Full Code status on the face sheet and spine of the hard chart, but again, no physician's order was present on the POS. Resident #35's medical record showed a discrepancy between the face sheet, which indicated a DNR status, and the POS, which had an order for Full Code status. Interviews with facility staff revealed that the Social Services Designee (SSD) was responsible for ensuring the code status was determined at admission and obtaining the necessary physician's order. However, the SSD could not write orders, and the resident was considered Full Code until the DNR paperwork was signed by a physician. The Director of Nursing (DON) and the Quality Assurance (QA) Nurse stated that they expected the code status orders to be documented on the physician orders. The Licensed Practical Nurse (LPN) and MDS Coordinator confirmed the process for identifying code status, but inconsistencies in documentation and obtaining physician orders led to the deficiencies identified in the report.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by multiple observations of worn and damaged furniture, peeling wallpaper, and exposed sheetrock in various rooms. Specific observations included worn seat cushion covers, peeled wallpaper, and scuff marks on walls in the 100 Hall, as well as loose and cracked molding and loose sheetrock tape in the 300 Hall. Additionally, the Spa Room was cluttered with stacked mattresses, cupcake pans, and miscellaneous debris, indicating a lack of organization and cleanliness. Interviews with staff and residents revealed a lack of communication and documentation regarding maintenance issues. A resident expressed dissatisfaction with the condition of a chair in their room, while housekeepers reported verbally notifying the maintenance department of issues but were unaware of a maintenance log. The Maintenance Supervisor acknowledged the difficulty in addressing environmental concerns without written documentation, and the Quality Assurance nurse noted the availability of replacement chairs in storage. The Administrator expected staff to use the maintenance log book to report concerns, but this practice was not consistently followed.
Inaccurate MDS Coding for Anticoagulant Therapy
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their medical records. For Resident #4, the annual MDS indicated that the resident did not receive an anticoagulant, despite the December 2024 Physician Order Sheet (POS) showing a diagnosis of personal history of thrombophlebitis and an order for desmopressin, an anticoagulant, to be taken twice daily. The resident's care plan, revised in February 2024, also confirmed that the resident was receiving anticoagulant therapy. For Resident #51, the annual MDS inaccurately indicated that the resident received an anticoagulant. However, the December 2024 POS showed a diagnosis of stroke and an order for aspirin, a nonsteroidal anti-inflammatory drug, rather than an anticoagulant. The resident's care plan, revised in October 2024, incorrectly noted that the resident was on anticoagulant therapy. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the MDS assessments should accurately reflect whether a resident is taking an anticoagulant.
Failure to Conduct PASARR Screening for Two Residents
Penalty
Summary
The facility failed to conduct the federally mandated Preadmission Screening and Resident Review (PASARR) for two residents, resulting in a deficiency. Resident #4, who was admitted with diagnoses of dementia and post-traumatic stress disorder, did not have the required level one PASARR screening documented upon admission. Similarly, Resident #43, admitted with bipolar disorder and schizophrenia, also lacked documentation of the necessary level one PASARR screening. The Social Service Director acknowledged that Resident #4's screening was incomplete and Resident #43's screening was rejected due to missing psychiatric documentation. The Administrator confirmed the expectation that a level one PASARR should be completed prior to a resident's admission.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to implement, monitor, and modify interventions to maintain acceptable nutritional status for a resident, leading to significant weight loss. The facility's policy required a designated weight champion to oversee residents at risk for weight loss, but there was no evidence of effective monitoring or intervention for the resident in question. The resident experienced a 10.38% weight loss over six months, with no documented assessment by the Registered Consultant Dietitian (RD) in October and November. The resident's care plan did not address weight loss with specific interventions, and there was no order for a multivitamin or weekly weights as recommended by the RD. Interviews revealed that the facility did not hold meetings to discuss residents' weights, and the RD suggested that bi-weekly weight meetings would be beneficial. The resident was not trying to lose weight and was not on any medications to aid in weight loss. The resident's family brought the weight loss to the facility's attention, indicating a lack of proactive monitoring by the facility. The Minimum Data Set (MDS) Coordinator and the Director of Nursing (DON) received the weight variance report but did not take appropriate action to address the resident's weight loss.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 8.11% for three residents out of eleven sampled. The errors involved improper administration of insulin and ondansetron. For Resident #20, a registered nurse (RN) administered 12 units of Humalog insulin without priming the Kwik Pen as per the manufacturer's instructions, which is required for each administration. Similarly, for Resident #38, the same RN administered 9 units of Novolog insulin without priming the Flex Pen, contrary to the manufacturer's guidelines. Additionally, Resident #34 was administered ondansetron, an anti-nausea medication, incorrectly. A certified medication technician (CMT) gave the resident the tablet with water, failing to instruct the resident to hold the medication on or under the tongue for it to be effective. Instead, the resident swallowed the tablet, which was not in accordance with the prescribed method of administration. Interviews with the RN and the Director of Nursing (DON) revealed a misunderstanding about the need to prime insulin pens with each use, and the facility's Quality Assurance (QA) Nurse confirmed that the facility follows the manufacturer's recommendations.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for one resident. During an observation, a registered nurse (RN) did not follow the facility's policy for EBP, which requires the use of gowns and gloves during high-contact resident care activities such as wound care. The RN did not put on an isolation gown, failed to perform hand hygiene before putting on gloves, and did not change gloves appropriately during the wound care process. Additionally, the RN disposed of biohazard waste improperly and did not perform hand hygiene after removing gloves. The facility also failed to use proper hand hygiene during blood sugar testing for four residents. The RN did not perform hand hygiene before putting on gloves and after removing them during the blood sugar testing procedures. This practice was observed consistently across multiple residents, indicating a systemic issue with adherence to the facility's infection control policies. The Director of Nursing acknowledged that the residents should have been on EBP and that proper hand hygiene should have been performed during these procedures.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to conduct the required twelve hours of annual in-service training for nurse aides, specifically in the areas of dementia care and abuse prevention. This deficiency was identified through interviews and record reviews, which revealed that two certified nurse assistants (CNAs), referred to as CNA A and CNA B, did not receive the necessary training. CNA A, hired in August 2022, attended only seven monthly in-services without documented time durations and did not participate in an annual competency in-service on dementia care. Similarly, CNA B, hired in November 2021, attended six monthly in-services, also lacking documented time durations, and missed the annual dementia care competency in-service. The facility's assessment, revised in February 2024, outlined the requirements for nurse aide in-service training, which included a minimum of twelve hours per year, dementia management training, and resident abuse prevention training. However, the facility did not provide a policy for nurse aide in-service training. During interviews, both the Director of Nursing and the Administrator acknowledged that nurse aide education should include dementia care and meet the twelve-hour annual requirement. The facility census at the time was 59, indicating a significant oversight in ensuring the competence of its nurse aides in critical areas of resident care.
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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