Hermitage Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Hermitage, Missouri.
- Location
- 18599 First Street, Hermitage, Missouri 65668
- CMS Provider Number
- 265239
- Inspections on file
- 16
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Hermitage Nursing & Rehab during CMS and state inspections, most recent first.
A resident with vascular dementia, who was generally independent and calm, was involved in an altercation with a CNA in the SCU hallway and bedroom doorway. Video showed the CNA grabbing the resident’s forearms and twice forcefully pushing the resident back into the room while the resident appeared to resist and gesture toward the day area. Another CNA reported hearing the CNA repeatedly yell at the resident to get back in bed while the resident refused, and observed the CNA holding and struggling with the resident’s arms. Shortly afterward, the resident exited the room visibly upset, loudly demanding that the CNA be arrested and pointing to a bleeding area on the forearm. Nursing staff and the DON later documented multiple bruises of varying sizes and shapes on both hands and forearms, which staff described as looking like someone had grabbed the resident, and other staff confirmed the resident had no recent falls, was not clumsy, and had no prior bruising.
The facility failed to consistently assess, document, and obtain appropriate treatment orders for wounds and orthotic use for three residents. One resident returned from the hospital with a forehead laceration and a prescribed wrist splint, but the care plan was not updated, a wound assessment was delayed for several days, there were no early orders to monitor the laceration or skin under the splint, and staff were confused about which arm required the splint, with observations showing the splint off and not monitored. Another resident with chronic leg ulcers had an active wound treatment order, yet MARs showed missed treatments, multiple weekly skin assessments documented skin as intact with no treatment in place, no wound assessments were available for an entire month, and observations revealed multiple open areas on the leg being treated under a single order, with dressings applied in a way that left an open area partially uncovered and adhesive on the wound bed. A third resident, care planned as at risk for skin breakdown, had a weekly skin assessment charted as intact and no nurse notes for several days, while CNAs reported a prior skin tear on the forearm that had been treated with steri-strips and bandages and had progressed to multiple scabbed areas with redness; the DON later confirmed there had been no earlier documentation or timely physician notification for treatment or monitoring orders.
A resident with dementia and a history of stroke was admitted without psychotropic medications and initially assessed as alert and pleasant, yet staff quickly obtained and administered IM haloperidol for attempts to ambulate without assistance, followed by multiple PRN and scheduled orders for risperidone, lorazepam, Zoloft, and Seroquel for behaviors such as anxiety, yelling, roaming, and standing up from a wheelchair. The facility did not complete a comprehensive assessment or develop a care plan addressing antipsychotic use, and nursing documentation frequently lacked detailed descriptions of behaviors, nonpharmacological interventions, or behavior monitoring at the time medications were given. Interviews with an RN, DON, NP, physician, and the Administrator confirmed that the indications and dosing for antipsychotics, including high-dose risperidone and IM haloperidol, were not appropriate for the behaviors described and that nonpharmacological approaches should have been attempted first, contrary to facility policy requiring residents to be free from chemical restraints and mandating thorough, interdisciplinary care planning.
Two residents with dementia made separate allegations of abuse that were not reported to facility leadership and DHSS within required timeframes. In one case, a CNA observed another CNA forcefully holding and pushing a resident by the arms while the resident resisted and later noted bruising; the CNA states they informed an LPN and the DON the same day, but the allegation was not reported to the state until several days later. In the other case, a resident repeatedly told a hospice RN and multiple CNAs and nurses that a man was raping them; staff variously "blew off" the statements, attributed them to confusion, or assumed others had reported them, and the allegation was not promptly reported to the DON or to DHSS. Staff interviews showed inconsistent understanding and practice regarding immediate internal reporting and the 2‑hour external reporting requirement for all abuse allegations, including those from cognitively impaired residents.
The facility failed to ensure immediate reporting, investigation, and protective measures for abuse allegations involving two residents. One resident with vascular dementia and severe cognitive impairment was observed by a CNA being grabbed and pushed by a CNA while resisting, later found with scattered bruising on both arms. The witnessing CNA reported the incident informally, but the LPN on duty denied receiving the report, another CNA did not escalate it, and the alleged perpetrator continued working alone on the special care unit. In a separate case, a cognitively impaired resident with dementia and psychiatric diagnoses repeatedly told a hospice RN that a man had raped the resident; the hospice RN did not document or formally report the allegation, attributing it to dementia. These actions and inactions conflicted with facility policy requiring immediate suspension of alleged perpetrators, prompt reporting to leadership and authorities, and timely completion of abuse investigations.
A resident with severe cognitive impairment, diabetes, edema, and dependence for ADLs developed a right heel pressure ulcer that was initially documented as an unstageable, fluid-filled blister and later as 100% eschar. Although the facility’s policy required ongoing and weekly skin and wound assessments with detailed documentation and regular reevaluation of treatment, multiple skin assessments recorded "no skin issues" while the MAR showed ongoing heel protectors and skin prep, and no wound observation reports were completed for an extended period. When an LPN later performed wound care, a notable odor was present and the heel showed a black scabbed area, yet the treatment order for skin prep had never been updated since initiation, and interviews with the DON, NP, hospice RN, and Administrator confirmed that weekly wound assessments had not been done, documentation was incomplete, and treatment had not been reevaluated despite changes in the wound.
Staff failed to timely obtain, track, and act on ordered urine lab tests for a resident with dementia, severe cognitive impairment, and bladder incontinence who had a UA and culture ordered for a suspected UTI. The urine specimen was not collected until four days after the order, and there was no documentation of efforts to obtain the specimen, contact the lab, or follow up on results for several days thereafter. When the culture ultimately showed high counts of Klebsiella aerogenes and Hafnia alvei resistant to nitrofurantoin, the practitioner ordered nitrofurantoin without documented acknowledgment of the resistance. Interviews with an LPN, NP, DON, and the Administrator showed that nurses were not routinely checking the lab website, there was no designated medical records staff monitoring labs, the DON did not call the lab or receive results, and leadership was unaware of expected lab turnaround times.
Failure to Protect a Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA. The resident had vascular dementia with agitation, was severely cognitively impaired, but was usually understood and usually understood others. The resident was generally pleasant, mostly independent with walking, dressing, toileting, and hygiene, and typically got up, dressed, and went to the dining/day area each morning. The resident resided on the special care unit (SCU) for safety and had no documented recent behavioral issues, aggression, falls, or injuries prior to the incident. The resident’s care plan included ensuring areas were free of hazards, redirecting the resident when entering unsafe areas, and preventing serious injuries related to memory/recall deficits. On the morning of the incident, video surveillance from the SCU hallway showed the CNA and the resident at the resident’s doorway. The CNA initially grabbed the resident’s right forearm while the resident stood in the doorway and the resident pulled away. Over several minutes, the resident and CNA appeared to gesture back and forth, with the resident pointing toward the day area and the CNA pointing toward the resident’s room. The video then showed the resident raising his or her arms in front of the CNA, the CNA knocking the resident’s arms down, then holding the resident’s forearms and pushing the resident back into the room. The CNA exited, closed the door, and walked toward the day area. The resident reopened the door and stood in the doorway again, at which point the CNA walked quickly back, grabbed the resident’s forearms, and again appeared to forcefully push the resident into the room while holding the resident’s forearms. A CNA who arrived on the unit around that time reported hearing the CNA repeatedly yell at the resident to get back in bed, while the resident yelled that he or she did not want to go back to bed. This CNA stated that upon looking into the room, the CNA had hands on the resident’s forearms and was struggling with the resident, who was trying to get loose, while the CNA continued to hold and push the resident toward the bed. The CNA told the staff member to leave the resident alone and then to leave the SCU. Another CNA reported that shortly afterward, the resident exited the room visibly upset, loudly stating that the person who had done this needed to be arrested, and pointed to a bleeding area on the forearm. This CNA and others described the resident as very upset and angry, and it reportedly took about two hours to calm the resident. Subsequent assessments documented multiple bruises on both of the resident’s hands and forearms in various sizes and shapes, including circular, linear, oblong, and rectangular bruises, as well as a scabbed area. Nursing staff and the DON observed these bruises and described them as appearing consistent with someone having grabbed the resident. Staff who knew the resident stated that the resident did not usually bump into things, was not clumsy, and had no recent falls. The resident’s physician stated that multiple bruises on the arms and hands would not be expected unless the resident was on many blood thinners, and that the only acceptable reason to grab a resident’s arms would be to prevent a fall or injury. The Administrator later confirmed that review of the video showed the CNA grabbing the resident by the arms and pushing the resident back into the room on two occasions, and that the resident’s responsible party reported bruises and an allegation that the CNA had abused the resident.
Failure to Assess, Document, and Care Plan Wounds and Orthotic Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to monitor, obtain, and document treatment orders and to care plan wounds and orthotic use for multiple residents, contrary to its wound care policy. One resident with vascular dementia and severe cognitive impairment sustained an unwitnessed fall in the special care unit dining area, resulting in a forehead laceration, right wrist sprain, closed head injury, and cervical sprain. The hospital discharge summary directed that the resident wear a right wrist splint until cleared by the physician and follow up with the primary physician. Upon return, nursing documentation noted the removable splint and Dermabond-closed laceration, but there was no immediate wound assessment; the first wound assessment was completed six days after the laceration occurred. The care plan was not updated to include the recent fall, laceration, or right wrist sprain, and there were no early physician orders to monitor the head laceration or the skin under the splint. Staff interviews revealed confusion about which arm required the splint, with some CNAs recalling the splint on the right arm and others stating it was always on the left, and observations showed the splint off and lying on the counter without documentation of refusal or monitoring. Another resident with severe cognitive impairment, intracerebral hemorrhage, and chronic leg wounds had an active order to cleanse the right calf wound, apply skin prep, calcium alginate, and cover with border gauze daily and as needed. Medication administration records showed the treatment was not documented as completed on at least two days, and January progress notes contained no documentation related to the right calf wound. Multiple weekly skin assessments in January and February documented skin as intact with no treatment in place, despite the ongoing wound treatment order and a wound management report later identifying an ulcer on the right ankle/lower calf with slough and drainage. Facility records showed missing weekly skin assessments on some dates and no wound assessments for January. Observations of wound care revealed the resident had multiple open areas on the right lower leg, including two wounds on the outer calf and later a total of five shallow open areas, but the nurse performed a single treatment based on one wound order, split a calcium alginate dressing between two wounds, and applied a bordered dressing that did not fully cover one open area and allowed the adhesive border to contact the wound bed. Staff and the nurse practitioner stated that all open areas should be assessed, documented, and have individualized orders, and that adhesive borders should not be placed directly on wound beds. A third resident with severe cognitive impairment, psychotic disorder, dementia, and total dependence for ADLs was care planned as at risk for skin impairment, with interventions including weekly licensed nurse skin checks and reporting any signs of skin breakdown to the charge nurse and physician. A weekly skin assessment documented intact skin with no issues, and there were no nurse progress notes for several days. However, observation showed the resident scratching the left forearm with long fingernails and having four scabbed areas with surrounding redness, including one large scabbed area and three smaller ones, uncovered and without visible ointment. Multiple CNAs reported that the areas began as a skin tear approximately one to two weeks earlier, initially treated with steri-strips, then covered with a bandage and later bordered gauze, and that additional open areas developed from adhesive or scratching. The DON stated not being aware of the areas until the date of surveyor observation and confirmed that nurses should document new skin tears in progress notes, notify the physician and family, and obtain treatment or monitoring orders, but there was no earlier documentation of the skin tear or monitoring in the record. The deficiency centers on the facility’s failure across these residents to consistently assess, document, obtain and follow treatment orders, and incorporate wounds and orthotic use into care plans as required by facility policy.
Failure to Assess, Care Plan, and Justify Antipsychotic Use for a Dementia Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive assessment and establish a care plan before initiating and escalating psychotropic and antipsychotic medications for a resident with dementia. The resident was admitted with diagnoses including dementia, anxiety, and cerebral infarction, and the hospital discharge summary showed no antipsychotic, antianxiety, or antidepressant medications at discharge. The admission physician note documented the resident as alert, oriented to self, pleasant, conversant, and following commands, with no documentation of a need for or orders for antipsychotic medications. The quarterly MDS indicated severe cognitive impairment, behavioral symptoms directed and not directed toward others one to three days a week, and that the resident received antipsychotic medication, but the facility did not provide a comprehensive care plan for the resident. On the evening of admission, nursing staff documented that the resident attempted to ambulate without assistance, did not accept redirection, and was brought to the nurses’ desk for closer monitoring. After the resident refused and spit out melatonin ordered by the NP, staff obtained an order for and administered a 2.5 mg IM haloperidol injection for a diagnosis of dementia, without documentation of a clinical rationale consistent with psychosis or serious harm. Over the following days, staff obtained multiple new and escalating psychotropic and antipsychotic orders, including PRN and then scheduled risperidone, lorazepam four times daily and then PRN, Zoloft, additional IM haloperidol orders (both lactate and decanoate), and later Seroquel, often for behaviors such as crawling on the floor, anxiety, yelling out, restlessness, roaming, and standing up from the wheelchair. The POS frequently listed diagnoses such as dementia without behavioral, psychotic, mood disturbance, and anxiety, or mild dementia with psychotic disturbance, while the record lacked corresponding comprehensive assessments or clear clinical justification for these medication regimens. Throughout this period, the facility failed to consistently monitor, document, and address the resident’s behaviors using nonpharmacological interventions. MAR entries often listed general reasons such as anxiety, yelling, roaming, restlessness, or aggression for PRN antipsychotic and antianxiety administration, but nursing progress notes on multiple dates did not describe the specific behaviors at the time of administration or any nonpharmacological approaches attempted. There was also missing documentation regarding receipt and discontinuation of lorazepam and new antipsychotic orders, and no separate behavior monitoring records or antipsychotic assessments were provided for the month. Interviews with an RN, the DON, the NP, the physician, and the Administrator confirmed that standing up from a wheelchair or similar behaviors were not appropriate indications for antipsychotic use, that risperidone dosing had been increased excessively, that IM haloperidol at the dose given was not appropriate, and that nonpharmacological interventions should have been tried first. The facility’s own policies required residents to be free from chemical restraints and required comprehensive, interdisciplinary care planning based on thorough assessment, but these processes were not followed for this resident. The facility also failed to develop and implement a care plan specifically addressing the use of antipsychotic medications for this resident. Despite repeated behavioral episodes documented in nursing notes—such as attempts to walk unassisted, sliding from the wheelchair, increased confusion, throwing items, yelling, cursing, spitting out medications, grabbing other residents, and multiple falls—there was no evidence of a comprehensive, individualized care plan that incorporated measurable goals, time frames, and nonpharmacological strategies to manage the resident’s dementia-related behaviors. The record did not show an interdisciplinary approach or revisions to a care plan in response to changes in the resident’s condition and medication regimen. Instead, the response to behaviors was largely pharmacologic, with frequent additions and changes to antipsychotic and antianxiety medications without the required assessment, documentation, and care planning to support their use.
Failure to Timely Report Allegations of Physical and Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all allegations of abuse were immediately reported to facility management and to the state agency within required timeframes. Facility policy required any employee or volunteer who became aware of abuse, neglect, exploitation, or misappropriation to immediately report to the Administrator, and required the Administrator or designee to report allegations of abuse or serious bodily injury to the state agency within two hours, including during nights and weekends. Despite this, staff did not promptly report an allegation of physical abuse involving one resident and repeated allegations of sexual abuse involving another resident, and one of the allegations was not reported to the Department of Health and Senior Services (DHSS) at all. For the first resident, who had vascular dementia with agitation and resided on a special care unit, the Administrator learned from the resident’s responsible party that the resident had bruises on the hands and arms and that an unnamed staff member had reported that a CNA had abused the resident. The Administrator’s subsequent interview with a CNA revealed that on a morning shift the CNA had entered the special care unit and observed another CNA in the resident’s room holding the resident’s forearms while the resident resisted and verbally objected to being put back to bed. The CNA reported hearing the other CNA repeatedly yell at the resident to get back in bed while the resident yelled that they did not want to go back to bed. The CNA stated that the two were struggling, that the resident tried to get loose while the CNA continued to hold and push the resident toward the bed, and that the resident later wanted to call the police and was difficult to calm. The CNA reported that shortly after the incident, they called the nurses’ station and told an LPN to come assess the resident’s arms, informed the LPN that the CNA had tried to hold the resident’s arms down and that the arms appeared bruised, and later that same day told other aides and the DON at the nurses’ station that the CNA had bruised the resident’s arms while trying to force the resident back into bed. The DON later documented scattered bruising on both upper extremities in various stages of healing and notified the physician. However, the allegation of abuse was not reported to DHSS until three days after the incident, and the LPN denied being informed of any incident involving the resident and the CNA. For the second resident, who had dementia, depression, anxiety disorder, delusional disorder, and paranoid personality disorder with severe cognitive impairment and dependence on staff for multiple ADLs, multiple staff and a hospice RN were aware that the resident had repeatedly stated that a man was raping them. The hospice RN reported that over approximately two weeks the resident said, "Don’t let that man in here. He’s raped me," and on a couple of occasions was tearful and said a man came in and raped them. The hospice RN stated that they "blew it off," believed they may have told an LPN or the DON, and did not know they had to report the allegation because the resident had dementia. A CNA recalled the resident stating at the nurses’ station that they had been raped, with the charge nurse present, and reported that the resident repeated the rape allegation a few days later during care; the CNA said they told an LPN or another nurse, who responded that the resident was confused. Other CNAs reported hearing that the resident had claimed rape multiple times, some stating they had reported the allegation to a charge nurse over two months earlier. Despite these repeated allegations and staff awareness, the facility did not self-report the rape allegation to DHSS until it was documented later as an allegation of sexual assault, and the DON stated that no one had informed them of any rape allegation, even though the DON considered such comments to be an allegation of abuse. Staff interviews showed inconsistent understanding and application of the requirement to immediately report all abuse allegations, including those made by confused residents, to facility leadership and to DHSS within two hours.
Failure to Immediately Report and Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all allegations of abuse were immediately reported, investigated, and that protective measures were implemented during the investigation for all residents, including two identified residents. Facility policy stated that residents would be free from abuse, that all employees alleged to have committed abuse would be suspended immediately pending investigation, and that accused residents would be isolated and monitored. The policy also required immediate or 24‑hour reporting to the State Survey Agency and law enforcement, and completion of investigations within five working days. Despite this, staff did not promptly report or act on allegations of abuse involving two residents, and the alleged staff perpetrator continued to work with residents after an incident was witnessed. For the first resident, who had vascular dementia with agitation, severe cognitive impairment, and resided on a special care unit, the Administrator learned of possible abuse only after the resident’s responsible party reported bruises on the resident’s hands and arms and relayed that an unnamed staff member had said a CNA abused the resident. A progress note documented scattered bruising on both upper extremities in various stages of healing, with the resident stating he or she woke up that way and denying pain or functional impairment. The Administrator’s subsequent review of video footage from the special care unit hallway showed the CNA grabbing the resident by the arms and pushing the resident back into the room on two occasions. Interviewed staff reported that on the morning of the incident, one CNA heard the alleged perpetrator repeatedly yelling at the resident to get back in bed, observed the CNA holding the resident’s forearms while the resident struggled to get free, and saw the CNA continue to push the resident toward the bed while holding the resident’s arms. That CNA stated he or she told the CNA to leave the room and the unit, and later called the nurse to look at the resident’s arms, expecting an incident report to be made. However, the LPN on duty that morning stated that no one informed him or her of any incident involving the resident and the CNA, and also reported not going to the special care unit to make rounds due to lack of time. Another CNA stated that he or she was told about the abuse by the witnessing CNA but did not report it, believing it had already been reported to the Administrator. The DON and other nursing staff indicated in interviews that grabbing a resident’s arms and causing bruising would be considered physical abuse and that alleged perpetrators should be removed from resident care areas and suspended pending investigation, but the Administrator confirmed that the CNA worked additional overnight shifts on the special care unit after the alleged abuse and before the allegation was brought to his or her attention. This sequence of events shows that the allegation was not immediately reported through the chain of command, the resident’s immediate safety was not ensured, and the alleged perpetrator was not promptly removed from resident care. For the second resident, who had dementia, depression, anxiety disorder, delusional disorder, paranoid personality disorder, severe cognitive impairment, and dependence on staff for multiple ADLs, there was also a failure to recognize and report an allegation of abuse. The resident’s care plan noted mood distress, crying, and cognitive deficits, and a progress note documented episodes of increased confusion and hallucinations, including the resident asking for specific individuals and misidentifying men in the facility as others. The hospice RN who visited weekly reported that during the prior two weeks the resident had said, “Don’t let that man in here. He’s raped me.” The hospice nurse stated that he or she “blew it off,” believed he or she may have mentioned the comments to an LPN or the DON, did not document the allegation in notes, and did not know it had to be reported because the resident had dementia. The DON stated that the hospice nurse and any staff with knowledge of the resident’s comments should have immediately notified the charge nurse and the DON, and that the resident’s statement was considered an allegation of abuse. This demonstrates that the facility did not ensure that all staff, including contracted hospice staff, recognized and immediately reported allegations of abuse, resulting in a failure to initiate an immediate investigation and protective measures for this resident as required by facility policy and regulation.
Failure to Assess, Document, and Reevaluate Treatment for a Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for one resident with a right heel pressure injury, in accordance with its own wound care policy. The resident had multiple diagnoses including diabetes, depression, and edema, severe cognitive impairment, delusions and hallucinations, and was dependent on staff for all ADLs except eating. The facility’s policy required ongoing skin assessments with weekly documentation, thorough wound documentation, reevaluation of dressing and skin integrity every shift, and regular reassessment of the wound’s response to treatment. Despite this, the facility did not consistently complete or document skin and wound assessments, did not accurately reflect the resident’s wound status in routine skin assessments, and did not update treatment orders as the wound evolved. The resident developed a right heel blister/pressure ulcer first documented in early November as an unstageable pressure ulcer measuring 4 cm by 8 cm, with subsequent documentation describing a fluid-filled blister with darkened skin and use of a protective boot and skin prep. Over November and December, wound observation reports and nursing notes showed changes in size and characteristics, including progression to 100% necrotic/eschar tissue, with measurements gradually decreasing to 3.5 cm by 4 cm. The care plan referenced a right heel blister/eschar and ongoing skin prep treatment, and the MAR reflected heel protectors and skin prep as completed. However, multiple skin assessments documented during this period and into January and February stated there were “no skin issues,” despite the ongoing presence of the right heel wound and continued treatment orders. Beginning in January, no wound observation reports were completed for the right heel wound, and there were no progress notes related to the heel wound for that month, even though the MAR continued to show heel protectors and skin prep as administered. In February, repeated skin assessments again documented no skin issues. When surveyors observed wound care in late February, an LPN removed the resident’s sock and noted a notable odor from the foot, stating the treatment should be re-evaluated and that the odor had been present since earlier in the week. A black, round scabbed area was observed on the right heel, and skin prep was applied. A subsequent nursing note described the wound as an unstageable right heel wound with necrotic tissue, borders no longer attached, and surrounding tissue pink and warm. Interviews with nursing staff, hospice staff, the DON, NP, and the Administrator confirmed that weekly wound assessments had not been completed since December, that the wound order for skin prep had not been changed since initiation, that hospice did not share wound assessments with the facility, and that skin assessments should have included the wound but instead repeatedly documented no skin issues. Throughout this period, the facility failed to follow its policy requirements for ongoing and weekly wound assessments, accurate documentation of wound characteristics, and timely communication and reassessment of treatment. The DON acknowledged that the former ADON had been responsible for wound assessments and that there had been no wound assessments since December, and stated he/she did not know why they were not done. The Administrator stated that staffing issues affected nurses’ completion of observations and follow-up for wounds, and that the ADON should complete weekly wound assessments and nurses should stage all wounds correctly and document monitoring of skin areas in progress notes. These actions and inactions resulted in a lack of current, accurate wound documentation, absence of documented reassessment of the wound’s response to treatment, and failure to update or reevaluate treatment orders despite ongoing necrotic tissue and later development of odor noted by staff.
Failure to Timely Obtain, Track, and Act on Urine Lab Results for Suspected UTI
Penalty
Summary
Facility staff failed to provide and follow up on ordered laboratory services for a resident with a suspected UTI. The resident, who had dementia with severe cognitive impairment, required moderate assistance with toileting and other ADLs, was dependent for hygiene, and was incontinent of bladder. A physician ordered a urinalysis (UA) and urine culture on 02/14/26 for diagnosis of UTI, but from 02/14/26 to 02/17/26 there was no documentation that staff obtained the UA, contacted the lab, encountered any difficulty obtaining the specimen, or received any results. The UA specimen was not collected until 02/18/26 at 7:41 p.m., four days after the initial order, despite a lab agreement stating that common tests would be reported the same day and most others within 24 hours, with routine lab days Monday through Friday. After the specimen was collected on 02/18/26, progress notes from 02/19/26 to 02/26/26 contained no documentation regarding the status of the UA, any follow-up with the lab, or any findings. The final UA and culture report, dated 02/27/26, showed growth of >100,000/ml Klebsiella aerogenes and >100,000/ml Hafnia alvei, with susceptibility testing indicating resistance to nitrofurantoin. On 02/27/26, staff documented that the UA with culture and sensitivity results were received and that the physician, who was in the facility, ordered nitrofurantoin 100 mg twice daily for seven days, 13 days after the initial UA order, without documentation of any discussion that the identified organisms were resistant to the prescribed antibiotic. Interviews revealed that nurses were not routinely checking the lab website for results, there was no medical records person monitoring labs, the DON acknowledged not calling the lab or receiving results and stated that no staff had checked on them, and the Administrator was unaware of expected lab turnaround times.
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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