Laverna Manor Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Savannah, Missouri.
- Location
- 904 Hall Avenue, Savannah, Missouri 64485
- CMS Provider Number
- 265787
- Inspections on file
- 30
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Laverna Manor Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to Initiate CPR for a Full Code Resident: A resident with cardiac and respiratory diagnoses was documented as Full Code and had a TPOPP/POLST requesting CPR if found without a pulse and not breathing. After the resident was found unresponsive, not breathing, and without a pulse, an LPN asked a family member whether CPR should be started and waited several minutes while the family member decided; CPR was not performed and the resident died at the facility. Interviews showed the LPN knew the resident was Full Code but did not initiate CPR, and staff stated CPR should have been started regardless of the family member’s statement.
Food service failed to provide meals at safe, appetizing temperatures and did not consistently follow the posted menu. Surveyors observed hot and cold items served without temperature checks, with breakfast items including a biscuit, omelet, milk, and juice served at improper temperatures and with poor appearance. Residents reported cold, dry, or burnt food, repetitive menus with too many sandwiches, too few salads and fresh fruit, and diabetic residents described meals that were too high in carbs and lacking protein. Staff also served chicken salad on plain white bread when croissants were unavailable and did not document a suitable substitute for missing taco salad items.
A facility failed to maintain professional standards of care when a resident with a PEG tube had no physician order for flushing before and after medications, another resident listed with Hospice lacked a hospice order in the POS, and a third resident received multiple crushed medications without an order to crush them. Staff observed the PEG tube medication administration, confirmed the hospice documentation gap, and acknowledged that crushed-medication instructions should have been in the record.
Expired medications and unlabeled opened medications were found in medication storage areas and carts, including Lorazepam, a Narcan nasal spray, a multivitamin, a TB PPD vial, and an opened insulin pen for a resident with Type 2 DM. Staff also failed to maintain refrigerator temperature logs and the freezer had heavy ice buildup, while interviews confirmed daily temperature checks and dating of opened medications were expected.
Surveyors found multiple food safety failures, including expired and undated food items stored in the refrigerator, staff preparing and handling food without required hairnets or beard nets, and food served without required temperature checks. Breakfast items were moved from the oven to the heating cart and steam line without being temped, and a dietary staff member also failed to wear proper hair restraints while preparing food.
Incomplete Antibiotic Stewardship Monitoring: The facility failed to maintain consistent antibiotic stewardship and infection surveillance tracking. Review showed missing monitoring records for several months, while four residents were receiving antibiotics for UTI and URI. The Infection Control Nurse, DON, and Administrator stated the binder should have been kept up to date, but the Infection Control Nurse reported she had been working frequently as a charge nurse and had not completed the required tracking.
The facility failed to provide required Medicare non-coverage notices for two residents. One resident did not have a NOMNC showing the right to appeal when Medicare Part A services ended, and another resident did not have a signed SNF ABN when Medicare-covered services were discontinued before benefit days were exhausted. The Social Services Director said she was responsible for completing the forms but could not locate the missing documents.
A quarterly MDS for a resident was transmitted well past the required timeframe. The RNC said the prior MDS coordinator had quit, an outside vendor later reported incomplete sections, and she then corrected and sent the assessment. The Administrator stated MDS assessments should be completed and submitted within required timeframes.
Improper catheter care was observed for a resident with an indwelling urinary catheter, dementia, and hospice services. CNAs cleaned the catheter tubing with disposable wipes by wiping toward the insertion site, while multiple staff members, including an RN, Infection Control Nurse, and DON, stated the tubing should be cleaned away from the insertion site.
Staff failed to follow infection control practices during resident care and medication administration. A resident with an indwelling urinary catheter was transferred and checked for brief changes without EBP or gloves, despite staff confirming those precautions were required. In a separate event, an insulin pen was used for a resident with diabetes without cleaning the pen port with alcohol before the needle was attached, and staff confirmed the port should have been wiped first.
Staff failed to properly secure a sling to a mechanical lift during a transfer, resulting in a resident with severe cognitive and physical impairments falling to the floor and sustaining pain to the shoulders and hip. Despite facility policy and equipment guidelines requiring verification of secure sling attachments, staff did not confirm all loops were attached before moving the resident, leading to the incident.
Two residents with cognitive impairment and pain management needs had fentanyl patches go missing, and staff failed to follow protocol by not conducting or documenting investigations into the missing controlled substances. Leadership was either not notified or did not ensure proper follow-up, resulting in unaccounted-for narcotics and a lack of compliance with facility policy.
A resident with multiple complex medical conditions fell from a mechanical lift and complained of pain. Although a physician ordered the resident to be sent to the hospital for x-rays and evaluation, facility administration directed staff to use mobile x-ray services at the facility instead. The physician and medical director both expected the original order to be followed, but the facility did not comply.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident's prescribed Oxycodone was found missing due to inadequate inventory procedures, as staff only counted in-use narcotic sheets and not full, unopened ones. This failure in controlled substance reconciliation and documentation made it impossible to determine when the medication was taken or who was responsible, and the loss was not identified until mid-shift rather than at shift change.
A resident with a history of sexual outbursts and severe cognitive impairment in a memory care unit inappropriately touched another cognitively impaired resident in a common area. The incident occurred while a CMT was preparing medications nearby, and both residents were unsupervised in close proximity despite known behavioral risks. The facility's abuse prevention measures did not prevent the incident, resulting in a failure to protect residents from abuse.
The facility failed to ensure accurate MDS assessments for five residents, affecting care planning. Discrepancies included incorrect coding of tobacco use and anticoagulant medications, contrary to RAI Manual guidelines. The MDS Coordinator followed external advice without verification, leading to misclassification. The administrator expected accurate assessments, revealing a gap between expectations and practice.
The facility failed to provide written transfer notices to two residents transferred to the hospital, as required by policy. Despite having medical conditions necessitating hospital transfers, there was no documentation of written notices in their EMRs. Staff interviews revealed reliance on verbal communication rather than written notices, which was confirmed by the Social Services Director.
The facility failed to provide written bed hold notices to two residents transferred to the hospital, as required by policy. Despite the policy's requirement for written information on bed-hold rights and transfer details, neither resident received such notices. Interviews with staff revealed reliance on verbal notifications, with no written documentation found in the residents' records.
A facility failed to complete and submit a quarterly MDS assessment for a resident, who had not been assessed in over 120 days. The resident's last completed MDS was an annual assessment, and the subsequent quarterly assessment was listed as 'In Progress' but not signed or submitted. The MDS Coordinator admitted the oversight during an interview. The resident has a complex medical history including cerebral infarction and Alzheimer's dementia.
A resident with a history of aggression hit another resident unprovoked, leading to a failure in protecting the resident's right to be free from abuse. Both residents were severely cognitively impaired. The incident was not documented in the nurse's notes, and the LPN forgot to document a skin assessment or progress note. The facility's abuse prevention policy was not effectively implemented, and the incident was substantiated by the Administrator.
A cognitively impaired resident with a known elopement risk was inadequately supervised, leading to multiple attempts to leave the facility unassisted. Despite being placed on one-on-one supervision after an initial elopement, the facility failed to continue this supervision or secure the resident's bedroom window. The resident subsequently exited through a second-story window, resulting in fractures to both heels and the lumbar spine. The facility's policies on accidents, wandering, and supervision were not adequately followed.
The facility did not prepare menus in advance or offer residents the opportunity to choose their meal options, nor were alternatives posted for residents to see. This affected three residents in a facility with a census of 58.
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Observations showed that hot food was not served at an appetizing temperature for several residents, one resident received meat that was too hard to cut, and another was not offered condiments. These issues affected all sampled residents in the facility.
The facility failed to maintain food safety standards by not ensuring proper food temperatures during distribution, reheating, and transport. Food was not consistently checked for safe temperatures, and meal trays were reused for different residents. Additionally, dishwashing temperatures were not regularly documented. The facility census was 58 residents.
The facility failed to provide a dignified dining experience by serving meals on Styrofoam plates with plastic cutlery due to a malfunctioning dishwasher. Three residents, who had no cognitive loss and required assistance with daily activities, expressed dissatisfaction with the disposable dinnerware. The dishwasher had been malfunctioning for over two months, leading to the use of paper products. Staff confirmed the ongoing issue and residents' dislike for the disposable dinnerware, but the Administrator did not consider it a dignity concern.
The facility failed to prepare menus in advance and offer meal choices to residents, affecting their dining experience. Three residents, who were cognitively intact, reported not being able to choose their meals, and observations showed no menus or alternatives posted. Staff interviews revealed issues with meal ticket management and a lack of a standard alternative menu.
The facility failed to serve meals at a safe and appetizing temperature, with residents frequently receiving cold food. Additionally, meals were not always served with appropriate textures or condiments, despite availability. Staff confirmed ongoing complaints about food temperature and taste.
The facility failed to maintain food safety standards, with food temperatures not consistently checked or maintained, improper food coverage during transport, and unsanitary practices such as reusing meal trays without sanitization. Additionally, the facility did not adhere to dishwashing procedures, with incomplete temperature logs and untrained staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The facility failed to provide CPR for one of 15 sampled residents, a resident who was documented as Full Code. The resident had diagnoses including paroxysmal atrial fibrillation, intracardiac thrombosis, shortness of breath, congestive heart failure, and ventricular tachycardia. The resident’s records showed a Full Code physician order, a baseline care plan listing Full Code status, and a TPOPP/POLST indicating the resident requested resuscitation/CPR if found without a pulse and not breathing. On the day of the event, the resident had earlier been seen short of breath, with oxygen saturation of 90% on 2 liters nasal cannula, which improved after oxygen was increased to 3 liters. Later, a family member alerted staff that the resident had a seizure. When the LPN arrived, the resident was in a recliner, not breathing, with no pulse or lung sounds. The resident then had agonal breathing. The LPN asked the family member whether CPR should be started and explained the resident was gasping to get oxygen to the brain. After approximately 3 to 4 minutes, the family member told the LPN not to perform CPR because it was not what the resident wanted, and CPR was not initiated. The resident died at the facility. Interviews showed the LPN knew the resident was Full Code but did not start CPR. The LPN stated the resident had told him/her that morning that he/she wanted to be DNR, but the LPN did not have time to call the physician or DON about a change in code status. Other staff stated that when a resident is not breathing or has no pulse, staff should verify code status and begin CPR if the resident is Full Code, regardless of what a family member says. The resident’s DPOA was listed in the record, but the DPOA was not invoked, and the resident’s documented code status remained Full Code.
Food Service Failed to Provide Palatable Meals and Follow Menus
Penalty
Summary
The facility failed to ensure residents were served food that was palatable, attractive, and at a safe and appetizing temperature, and it also failed to follow the planned menus. Survey observations, interviews, and record review showed that hot and cold foods were not consistently temperature-checked during meal service, and several meals were served in a manner that did not match the menu or appeared unappetizing. This affected 8 of 15 sampled residents, including residents with intact cognition, moderate cognitive impairment, malnutrition, diabetes, anemia, stroke, coronary artery disease, Alzheimer’s disease, anxiety, and depression. During breakfast service, hot items including biscuits, oatmeal, and cheese omelets were cooked and placed in the oven, then removed and transported without temperatures being taken. At the steam line, staff served the food without checking temperatures. The breakfast test tray later showed a biscuit at 88.7 degrees F, a cheese omelet at 134.0 degrees F that visually appeared to be scrambled eggs with a small amount of cheese, milk at 52.2 degrees F, and orange juice at 60.3 degrees F. Residents reported that food was often cold, dry, greasy, or otherwise unappetizing, and one resident said the food was terrible and lacked healthier options such as salads and fruit. Menu planning and menu execution also did not match resident needs or the posted menu. A resident requested bacon at breakfast but was told it was not on the menu and was not offered a substitute. The cycle menu showed repetitive breakfast menus, sandwiches as the main course for half of dinner meals, limited salads, and limited variety in desserts. At lunch, the menu listed chicken salad on a croissant, but no croissants were available, so staff placed chicken salad on plain white bread in a way that obscured the filling and did not improve presentation. A resident with diabetes and renal failure reported being served meals that were too high in carbohydrates, lacking protein, and missing items such as chips, salsa, and dressing for a taco salad. The menu substitution log also showed missing items without a suitable substitute documented. Residents and staff repeatedly described the menu as repetitive, with too many sandwiches, too few salads and fresh fruits, and food that was not appealing or served as planned.
Missing Orders for PEG Tube Flushing, Hospice, and Crushed Medications
Penalty
Summary
The facility failed to ensure services provided or arranged met professional standards of quality when it did not have a physician order for PEG tube flushing for a resident who was not cognitively intact, dependent on nursing staff for all cares, and had diagnoses including stroke, inability to swallow, and tube feedings for nutritional needs. The resident’s March 2026 POS included enteral feeding orders for Two Cal HN at 50 ml/hour for 20 hours and a water flush of 200 ml every four hours, along with an order to check tube placement before formula, medication administration, and flushing, but there was no order specifying flushing before or after medications, the amount of water to use, or how often to flush for medication administration. During observation, an RN administered medication using 10 ml of water before and after the medication and stated there should have been an order for tube flushing with water before and after medications. The facility also failed to ensure a resident had a physician order for Hospice even though the resident’s face sheet listed Hospice as the primary payer and the electronic record contained a hospice order dated 3/11/26. The resident’s POS for March 2026 did not include an order for Hospice, and there was no admission or start date for hospice services located in the electronic medical record. RN A stated the resident was admitted on Hospice but there should still be a physician order for it, and the DON stated there should be a physician order for a resident to be on Hospice. In addition, the facility failed to ensure a resident who required crushed medication had an order for medications to be crushed. The resident’s care plan identified the resident as not cognitively intact, taking medication for depression, and having a communication problem related to dementia, but the order summary and MAR for March 2026 did not include instructions for crushing medications. During observation, a CMT crushed multiple medications, including anastrozole, furosemide, gabapentin, paroxetine, Vitamin D, aspirin, and Echinacea, and placed them in pudding for administration. The CMT, RN A, the Infection Control Nurse, and the DON all stated that an order should have been present for medications to be crushed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to policy in the North medication room and the North nurse’s cart. During observation and interview, staff found expired medications and biologicals that had not been discarded, including an opened bottle of multivitamin that expired in 2/2026 and a Narcan nasal spray with an expiration date of February 2026 that no longer had a pharmacy label or resident name on it. The refrigerator in the memory care unit medication storage room did not have a temperature log, and the small refrigerator in the North medication room also lacked a temperature log. The freezer in the North medication room had a large amount of ice buildup, and staff stated the freezer should be defrosted and refrigerator temperatures should be checked daily. Opened bottles of Lorazepam were not dated when opened for four sampled residents. Resident #67 had an opened vial filled on 1/19/26 with no open date, Resident #5 had an opened vial filled on 10/4/25 with no open date, Resident #1 had an opened vial filled on 2/16/26 with no open date, and Resident #59 had an opened vial in the nurse’s cart with no open date. The manufacturer guidance stated opened liquid Lorazepam was good for 90 days when stored properly, and staff acknowledged the bottles should have been dated when opened. A house stock vial of Tuberculin PPD also had no open date, and staff stated it should have been dated when opened and discarded after 30 days per policy. Resident #56, who had Type 2 diabetes and was dependent on staff for physical, emotional, and intellectual needs, had an order for Degludec insulin 14 units subcutaneously at bedtime. Observation showed the resident’s Degludec insulin pen in the memory care medication cart was opened with no date indicating when it had been opened. Manufacturer guidance reviewed by surveyors stated the insulin pen was only good for 56 days after opening. Staff interviews confirmed insulin pens should be dated when first opened so staff would know when they expire.
Food Safety Failures in Kitchen and Dining Service
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety. During kitchen observations, surveyors found multiple expired food items stored in the refrigerator, including tuna casserole, sliced cheese, whipped topping, salad dressing, Miracle Whip, mustard, and a garnish container with sliced tomatoes and pickles. A bowl of sliced strawberries in juice was also observed without a label or date. Facility staff were observed preparing food while not wearing required hair restraints, including a dietary staff member not wearing a beard net over facial hair and not wearing a hairnet under a ballcap, with uncovered hair exposed on both sides of the head. Staff were also observed cleaning, handling leftovers, and washing dishes without hairnets and beard nets. Surveyors also observed failures in food temperature monitoring. Pre-cooked bacon was placed in the oven and later removed without a temperature check. On another observation, breakfast items including biscuits, cheese omelets, and oatmeal were removed from the oven, placed in a heating cart, and then placed on the steam line in the dining room without temperatures being taken before service. Food was observed uncovered and ready to serve on the steam line with no temperatures taken before serving the first meal to residents. The dietary manager stated that temperatures should be taken during cooking, when food is removed from the oven prior to service, and just prior to serving from the steam line, and that opened containers should be dated and leftovers discarded after three days.
Incomplete Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to establish an antibiotic stewardship program that included consistent monitoring of antibiotic use and a system for tracking antibiotic use for residents. Review of the facility’s antibiotic stewardship policy, dated December 2024, showed the program was intended to monitor antibiotic use through core elements including tracking how and why antibiotics are used, the amount used, and adverse outcomes, along with education of staff, residents, and families. However, review of the antibiotic stewardship and infection surveillance book showed no tracking of antibiotic use or infection surveillance for August 2025, September 2025, October 2025, February 2026, and March 2026. Clinical progress notes showed that four residents were receiving antibiotics in March 2026: one resident was started on Cephalexin for UTI, two residents were started on Cefpodoxime for URI, and one resident was started on Trimethoprim for UTI. During interviews, the Infection Control Nurse, Administrator, and DON stated the surveillance and stewardship binder should have been kept up to date and that tracking for February and March 2026 should have been completed. The Infection Control Nurse also stated she had been working frequently as a charge nurse and had not had time to complete the antibiotic stewardship and infection surveillance documentation.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue required Medicare non-coverage notices for two residents. For Resident #70, the record showed a physician’s order for the last covered day for Medicare Part A services on 9/25/25, and progress notes indicated the facility initiated discharge from Medicare Part A services when benefit days were not exhausted on that date. However, the facility could not show that a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), which informs the resident of the right to appeal and how to request an immediate appeal, was issued. For Resident #66, the record showed a physician’s order for the last covered day for Medicare service on 3/6/26, and progress notes indicated the facility initiated discharge from Medicare Part A services when benefit days were not exhausted on that date. The facility could not show that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), which explains that certain services were no longer covered and the associated cost, was signed by the resident. During interview, the Social Services Director said she was responsible for completing these forms and was unable to find the missing documents for both residents.
Late Transmission of MDS Assessment
Penalty
Summary
The facility failed to electronically transmit a quarterly MDS assessment for one resident within the required timeframe. The resident’s quarterly MDS had a care plan completion date of 02/03/26, but the assessment was not transmitted and accepted until 03/12/26, which was 37 days late. The facility’s policy stated that resident assessments are to be submitted in accordance with current federal and state timeframes, and the RAI Manual required all other MDS assessments to be submitted within 14 days of the MDS completion date. During interview, the Regional Nurse Consultant said she had been responsible for the MDS for the past month and a half and acknowledged that the resident’s quarterly MDS was late. She stated the previous MDS coordinator quit around mid-January and that the facility used an outside vendor that only notified them the day before that sections of the MDS were incomplete. She said she corrected the sections and sent the completed MDS. The Administrator stated that MDS assessments should be completed and sent within the required timeframes.
Improper Catheter Care During Urinary Catheter Maintenance
Penalty
Summary
The facility failed to ensure appropriate catheter care was provided for one resident with an indwelling urinary catheter. The resident was not cognitively intact, was dependent on staff for activities of daily living, resided on the memory care unit, received hospice care, and was incontinent of bowel. The resident also had diagnoses of non-Alzheimer's dementia, anxiety, and depression. The resident's record showed an order for cephalexin for a urinary tract infection, and the facility's urinary catheter care policy directed staff to cleanse and rinse the catheter from the insertion site outward using a clean washcloth with warm water and soap. During observation, two CNAs performed catheter care and used disposable cleansing wipes to clean the catheter tubing while wiping toward the catheter insertion site. Interviews with the CNAs, a CMT, an RN, the Infection Control Nurse, and the DON all confirmed that catheter tubing should be cleaned by wiping away from the catheter insertion site. The facility policy did not address the use of disposable wipes during catheter care, and the observed care did not follow the direction described by staff during interviews.
Infection Control Failures During Resident Care and Insulin Pen Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not use enhanced barrier precautions during direct care for a resident with an indwelling urinary catheter. Resident #29 had non-Alzheimer's dementia, anxiety, depression, was not cognitively intact, was dependent on staff for activities of daily living, resided on the memory care unit, received hospice care, and was incontinent of bowel with an indwelling urinary catheter. During observation, CNA E and CMT D transferred the resident from a wheelchair to the bed without wearing a gown and gloves, and CNA E touched the resident's brief to check whether it needed to be changed without gloves or a gown. Staff interviews confirmed that EBP should have been used during this care and that gloves should have been worn when checking the brief. The facility also failed to follow proper insulin pen handling during medication administration for Resident #69. The resident's March 2026 orders included Basaglar KwikPen 50 units daily for diabetes mellitus. During observation, CMT A sanitized hands, applied gloves, attached the needle to the insulin pen, primed it, and administered the insulin, but did not clean the tip of the insulin pen with alcohol before attaching the needle. Staff interviews later confirmed that the port of the insulin pen should have been cleaned with an alcohol wipe before the needle was attached, and the facility did not provide a policy for insulin pen use.
Failure to Secure Sling During Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
Facility staff failed to ensure a safe transfer of a resident with significant cognitive and physical impairments by not properly securing the sling to the mechanical lift during a transfer from bed to shower chair. The resident, who had a history of stroke, Alzheimer's disease, hemiparesis, and was assessed as requiring extensive assistance with all activities of daily living, was being transferred by two CNAs using a mechanical lift and mesh sling. According to interviews and documentation, one of the lower sling loops became detached from the lift during the maneuver, causing the resident to fall from the lift to the floor, resulting in pain to the resident's shoulders and left hip. The facility's policy on safe lifting and movement of residents required staff to use appropriate techniques and devices, ensure slings were properly attached, and verify secure connections before moving residents. The user manual for the mechanical lift also specified that all sling attachments must be checked before lifting and moving a patient. Despite these requirements, staff did not confirm that all sling loops were securely attached before proceeding with the transfer. Both CNAs involved in the transfer stated that they each attached loops on one side of the sling, but during the transfer, a loop on the left lower side came off, leading to the resident's fall. Following the incident, the resident was assessed by nursing staff and reported significant pain. The primary care physician was notified and initially ordered the resident to be sent to the hospital for evaluation, but administration directed that mobile x-rays be performed at the facility instead. The resident was subsequently treated for pain. Interviews with staff, including the DON and administrator, confirmed the expectation that staff ensure slings are securely attached before transfers, but this was not done in this case, directly leading to the resident's fall and injury.
Failure to Investigate and Account for Missing Fentanyl Patches
Penalty
Summary
The facility failed to ensure that two residents were free from misappropriation of their controlled pain medication, specifically fentanyl patches, when staff did not follow established protocols for investigating and accounting for missing patches. For one resident with significant cognitive loss and total dependence on staff for activities of daily living, a fentanyl patch was found missing during a scheduled change. The nurse and CNA searched the resident's environment but did not locate the patch, and although the Director of Nursing (DON) was notified via a communication application, no formal investigation or documentation was completed, and the nurse was not questioned further about the incident. A second resident, who had mild cognitive loss and required moderate assistance with daily activities, also experienced a missing fentanyl patch. The resident reported being in severe pain when the patch was discovered missing at the time of a scheduled change. The nurse applied a new patch, but no investigation was initiated, and the resident was not questioned about the missing patch. The DON was unaware of this incident and did not conduct or document an investigation. Interviews with facility leadership, including the DON, Medical Director, President of Clinical Operations, and Administrator, revealed that they expected missing narcotics to be reported, investigated, and documented. However, in both cases, there was a lack of follow-through on these expectations, and the missing patches were not accounted for or formally investigated, contrary to facility policy and standard practice for controlled substances.
Failure to Follow Physician's Order for Hospital Evaluation After Resident Fall
Penalty
Summary
The facility failed to follow a physician's order for a resident who experienced a fall from a mechanical lift. After the fall, the resident was found on the floor, covered with a blanket, and was assessed by an LPN. The resident, who had a history of cerebral infarction, Alzheimer's disease, hemiplegia, and other significant medical conditions, complained of pain in the shoulders and left hip. The physician was notified and gave a direct order to send the resident to the hospital for x-rays and evaluation. Despite the physician's order, facility administration instructed staff not to send the resident to the hospital, but instead to use mobile x-ray services at the facility. The LPN communicated this change to the physician, who reluctantly agreed to the use of mobile x-rays only if they could be performed within the hour, but expressed disagreement with the decision, stating that hospital x-rays are superior and that residents who fall from such a height should always be sent to the hospital for evaluation. The medical director and DON both stated that physician orders are expected to be followed, and the administrator indicated a preference for using contracted mobile x-ray services. The deficiency occurred because the facility did not adhere to the physician's explicit order to send the resident to the hospital following a significant fall, instead substituting mobile x-rays at the facility. This action was taken despite the physician's and medical director's expectations that such orders be followed, and without documented justification for not following the original order.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a significant quantity of the resident's prescribed narcotic medication, Oxycodone 5mg tablets, was found missing. The resident, who had diagnoses including depression, dementia, heart disease, and low back pain, was prescribed Oxycodone to be taken every eight hours. The missing medication was discovered after it had been received and verified by staff, but the loss was not identified until the middle of a shift rather than at shift change, as required by policy. The facility's investigation did not clearly state the reason for initiation, did not identify an alleged perpetrator, and failed to address inventory procedures or pinpoint when the medication went missing. Interviews with staff and review of facility policies revealed that, at the time of the incident, the process for counting controlled substances was inadequate. Staff only counted in-use sheets of narcotics and did not include full, unopened sheets in their shift-end counts, making it impossible to determine when the medication was taken or who was responsible. The count sheets and medications were accessible to all staff with access to controlled drugs, and the lack of comprehensive inventory controls prevented the facility from identifying the responsible party or the exact timing of the loss. The police investigation also noted the absence of proper inventory controls over the controlled medication.
Failure to Prevent Resident-to-Resident Sexual Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident, both with severe cognitive impairments, was able to physically touch the first resident inappropriately in a common area. The incident occurred when one resident, diagnosed with Alzheimer's disease, dementia with agitation, and delusional disorder, was walking through the memory care unit and was approached by another resident with Alzheimer's disease, a history of traumatic subdural hemorrhage, and mild cognitive impairment. The second resident, who had a documented history of behavior problems related to sexual outbursts and grabbing staff, reached out and ran a hand up the inside of the first resident's thighs, grabbing the genital area as the first resident walked by. At the time of the incident, the first resident had severely impaired cognition, displayed wandering behavior, and was sometimes understood in communication. The second resident also had severely impaired cognition and was noted to have behavior problems, including sexual outbursts, with care plan interventions instructing staff to redirect and distract the resident when inappropriate behaviors occurred. The incident was witnessed by a Certified Medication Technician (CMT) who was preparing medications in the common area and observed the inappropriate contact as it happened. Both residents were in the common area of the memory care unit, unsupervised in close proximity, despite the known behavioral risks associated with the second resident. The facility's abuse prevention policy required protection of residents from abuse by anyone, including other residents, but the measures in place at the time did not prevent the incident from occurring. The event was reported to the charge nurse, and both residents were assessed with no injuries noted.
Inaccurate MDS Assessments Affect Resident Care Planning
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five residents, which could potentially affect their care planning and provision. The Director of Nursing confirmed the use of the Resident Assessment Instrument (RAI) Manual, and the facility policy required comprehensive assessments to be conducted according to the RAI Manual's criteria and timeframes. However, discrepancies were found in the coding of tobacco use and anticoagulant medication, which were not aligned with the RAI Manual guidelines. For one resident, the MDS did not reflect their tobacco use, despite observations and documentation indicating they were a regular smoker. The MDS Coordinator acknowledged this might have been an oversight. For other residents, the MDS inaccurately coded the use of anticoagulant medications, listing antiplatelet medications like aspirin and Plavix as anticoagulants, contrary to the RAI Manual's instructions. The MDS Coordinator mentioned receiving guidance from an external auditing company, which led to the incorrect coding. The inaccuracies in the MDS assessments were identified through interviews, record reviews, and observations. The MDS Coordinator admitted to following external advice without verifying it against the RAI Manual, resulting in the misclassification of medications. The facility's administrator expected the MDS to accurately reflect residents' conditions, highlighting a gap between expectations and practice.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to two residents, R29 and R61, who were transferred to the hospital. This deficiency was identified during a review of records, interviews, and policy examination. The facility's policy requires that residents and their representatives receive written notice detailing the reason for transfer, the location, and information on how to appeal the transfer. However, this procedure was not followed for the two residents in question. Resident R29, who had medical diagnoses including chronic obstructive pulmonary disease, cerebral infarction, and hemiplegia, was transferred to the hospital in April. Despite the transfer, there was no documentation in the electronic medical record (EMR) indicating that a written notice of transfer was provided. Similarly, Resident R61, with diagnoses such as cystitis, dementia, and uterine cancer, was transferred to the hospital in July. Again, there was no evidence in the EMR of a written notice being given. Interviews with facility staff revealed that the process for emergent transfers involved verbal communication with the family and the Director of Nursing, but not the provision of written notices. The Social Services Director confirmed that the required documentation was not completed for these residents. This lack of adherence to policy potentially left residents and their representatives without crucial information regarding their transfers and their rights to appeal.
Failure to Provide Written Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, R29 and R61, who were transferred to the hospital, as required by their policy. The policy mandates that residents or their representatives receive written information about bed-hold rights and limitations, payment policies, and transfer details prior to any transfer or therapeutic leave. However, during interviews and record reviews, it was found that neither resident received such a notice. R29, who was hospitalized for kidney stones, confirmed she did not receive a written notice, and her electronic medical record showed no evidence of one being provided. Similarly, R61, who was transferred to the hospital after being found outside, also had no documentation of receiving a written bed hold notice in her records. Interviews with facility staff, including the Administrator, RN1, and the Social Services Director, revealed a lack of adherence to the policy. RN1 described the process of transferring residents, which included verbal notifications to families but not the provision of written notices. The Social Services Director acknowledged that the nursing staff was responsible for providing the bed hold notice, but it was not done in these cases. The absence of written documentation for both residents indicates a systemic issue in the facility's process for handling emergent transfers and ensuring compliance with their own policies.
Failure to Complete and Submit Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed and submitted for processing for a resident, identified as R14, who had not received an assessment in over 120 days. This deficiency was identified during a review of records, interviews, and the Resident Assessment Instrument (RAI) manual. The facility's policy, revised in March 2022, mandates that comprehensive assessments be conducted according to the criteria and timeframes established in the RAI User Manual. The October 2023 RAI Manual specifies that quarterly non-comprehensive assessments are due within 92 days after the Assessment Reference Date (ARD) of the most recent assessment. R14's electronic medical record (EMR) showed that the last completed and accepted MDS was an annual assessment with an ARD of 05/16/24. A quarterly MDS with an ARD of 08/15/24 was listed as 'In Progress' but had not been signed and submitted as of 10/08/24. During a telephone interview, the MDS Coordinator acknowledged that the quarterly assessment for R14 was missed, despite being on the list for completion in August. The resident's medical history includes cerebral infarction, hemiplegia, dysphagia, esophageal obstruction, heart failure, Alzheimer's dementia, depression, hypothyroidism, atrial fibrillation, chronic respiratory failure, anxiety disorder, and pain.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a resident with a history of aggression hit another resident unprovoked. Resident 42, who was severely cognitively impaired, was hit on the shoulder by Resident 23, who also had severe cognitive impairment and a history of physical aggression related to dementia. The incident occurred when Resident 23 entered Resident 42's room and hit her with a closed fist. This incident was not documented in the nurse's notes, and there was no immediate documentation of a skin assessment or progress note by the LPN who was informed of the incident. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of documentation and follow-up after the incident. The LPN admitted to forgetting to document the incident due to being overwhelmed, and the Director of Nursing was not present at the time. The Administrator confirmed the incident was substantiated and that Resident 23 was placed on 1:1 supervision until discharged for a psychiatric evaluation. The failure to document and address the incident promptly had the potential to affect all residents in the secured unit.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident with a known elopement risk. The resident, who had been admitted with dementia and a history of exit-seeking behavior, was involved in multiple incidents where they attempted to leave the facility unassisted. On one occasion, the resident became combative when staff tried to redirect them back inside from an outside activity and managed to reach the parking lot. The resident also threw objects out of a dining room window and later eloped through the same window, which was six feet above the ground. Despite being placed on one-on-one supervision after the first elopement, the facility did not continue this supervision or secure the resident's bedroom window. Consequently, the resident removed the window screen and exited through a second-story window, approximately 13 feet above a paved sidewalk, resulting in fractures to both heels and the lumbar spine. The facility's policies on accidents, wandering, and supervision were not adequately followed, as the resident's high risk for elopement was not effectively managed. Interviews with staff revealed that the resident had been exit-seeking since admission, and family members had previously struggled to keep the resident inside at home. Staff observed the resident's attempts to open windows and doors, and although medication was administered to manage agitation, the resident's behavior persisted. The facility's failure to maintain one-on-one supervision and secure all potential exit points contributed to the resident's injuries.
Failure to Prepare and Post Menus in Advance
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and developed to meet resident choices. Specifically, menus were not posted in advance, residents were not offered the opportunity to choose their menu options, and alternatives were not visibly posted for residents. This deficiency affected three out of five sampled residents, with the facility having a census of 58.
Deficiencies in Food Service Quality
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for four residents. Additionally, one resident was served meat that was too hard to be cut, and another resident was not offered condiments. These deficiencies were noted for all five sampled residents in a facility with a census of 58.
Deficiencies in Food Service Safety and Temperature Control
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, resulting in multiple deficiencies related to food storage, preparation, and service. Staff did not maintain food temperatures during distribution from the kitchen to the steam table and from the service point to resident delivery, allowing food to remain in the danger zone. Additionally, the facility did not check the temperature of reheated food on the steam table or food warmed in the microwave to ensure it was at a safe temperature. There was also a failure to cover all foods during transport to the special care unit. Furthermore, the facility reused meal trays for meal service delivery to other residents in the dining room, compromising safe food preparation. Lastly, the facility did not consistently check and document dishwashing temperatures on the temperature log daily. The facility census was 58 residents.
Use of Styrofoam Dinnerware Due to Dishwasher Malfunction
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by serving meals on Styrofoam plates with plastic cutlery due to a malfunctioning dishwasher. This issue affected three residents who were observed and interviewed, all of whom expressed dissatisfaction with the use of disposable dinnerware. The residents, who had no cognitive loss and required varying levels of assistance with activities of daily living, preferred to eat on glass dishes. The facility's policy on dignity emphasizes providing a dignified dining experience, which was not upheld in this situation. The dishwasher had been malfunctioning for over two months, leading to the use of paper products for meal service. Staff interviews revealed that the dishwasher was fixed and broke down multiple times, resulting in the continued use of Styrofoam plates. The Dietary Director and CNAs confirmed the ongoing issue with the dishwasher and the residents' dislike for the disposable dinnerware. The Administrator acknowledged the dishwasher's problems but did not consider the use of Styrofoam a dignity concern, despite residents' preferences.
Failure to Provide Menu Choices and Alternatives
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and that residents were given the opportunity to choose their meal options. This deficiency was observed when menus were not posted in advance, and residents were not offered choices or alternatives. This affected three of the five sampled residents, who were cognitively intact and capable of making their own meal choices. The facility's policy, 'The Dining Experience,' aimed to provide a person-centered dining experience, but this was not implemented effectively. Resident #2, who had a history of stroke and dysphagia, reported never being able to choose meals except at breakfast. Resident #3, with renal failure and other health issues, also stated they could not choose their meals. Resident #4, who had impaired vision and depression, mentioned being forgotten at lunch and having to wait for meals to be prepared. Observations showed no menus or alternative options were posted in the dining room, and meal tickets were mishandled, leading to confusion and delays in meal service. Interviews with staff revealed that the facility did not have a standard alternative menu, and meal tickets were often lost, causing residents to miss meals. The Dietary Manager admitted that menus were not posted since new ownership took over, and residents were informed of food choices through a printed ticket system. The Administrator was unaware of the requirement to post menus, indicating a lack of communication and organization in meal service management.
Deficiency in Meal Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for several residents, with meals often arriving cold. For instance, one resident reported receiving their meal an hour late, resulting in cold food. Another resident expressed dissatisfaction with the quality and temperature of the food, noting that it was generally not good and often cold. Additionally, the facility did not provide appropriate food textures and condiments as per residents' preferences and dietary needs. One resident was served a hamburger on bread without the desired condiments like pickles and cheese, despite the facility having these items available. Another resident was served meat that was too hard to cut, indicating a failure to provide food that met the required texture and consistency for safe consumption. The facility's failure to maintain proper food temperatures was further evidenced by a test tray showing food items below safe holding temperatures. Staff interviews confirmed that residents frequently complained about the temperature and taste of the food, with trays often left sitting out before being served. The dietary manager acknowledged the issue with food temperatures and the lack of condiments, while the administrator was aware of complaints but attributed them to age-related loss of taste buds.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, resulting in multiple deficiencies related to food storage, preparation, and service. Observations revealed that food temperatures were not consistently maintained within safe ranges during distribution from the kitchen to the steam table and from the service point to resident delivery. Specifically, several food items, such as pureed carrots, ground chicken, and pureed chicken, were found to be below the required serving temperature of 135 degrees Fahrenheit. Additionally, the facility did not consistently check the temperature of food reheated in the microwave, and there was a lack of documentation for serving temperatures, which were only recorded for cooking temperatures. The facility also failed to ensure proper food coverage during transport, as observed with hall trays where desserts and soups were not covered. This lack of coverage was confirmed by interviews with staff, who indicated that only the main dish was typically covered. Furthermore, the facility did not maintain sanitary conditions during meal service, as evidenced by the reuse of meal trays without proper sanitation, which could lead to cross-contamination. The Dietary Manager acknowledged that reusing trays without sanitization was not sanitary. Additionally, the facility did not adhere to its own policies regarding dishwashing procedures. The dishwasher temperature log was not consistently completed, with records showing it was only filled out once a day instead of the required three times. The Dietary Manager admitted that the staff was new and unaware of the need to record temperatures on the dishwasher sanitation log. These deficiencies highlight significant lapses in maintaining food safety and sanitation standards, as required by local, state, and federal regulations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
