Life Care Center Of Grandview
Inspection history, citations, penalties and survey trends for this long-term care facility in Grandview, Missouri.
- Location
- 6301 East 125th St, Grandview, Missouri 64030
- CMS Provider Number
- 265355
- Inspections on file
- 24
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Life Care Center Of Grandview during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was startled by a door opening on a locked memory care unit, fell onto the right side, and exhibited pain responses when the right leg was touched. Facility staff notified hospice, and a hospice nurse later assessed the resident, documented no pain complaints and no new orders, and stated they would inform the family. However, facility records contained no documentation that the resident’s responsible party was notified on the day of the fall, and there was no follow-up by facility staff to verify that hospice had contacted the family, despite staff and leadership acknowledging that nurses are responsible for immediately notifying responsible parties of changes in condition and that this notification should occur regardless of hospice involvement.
Multiple incidents of physical aggression occurred between residents, including one resident striking another in the head after a verbal exchange, another resident punching a peer in the face resulting in injuries, and a third incident where hot sauce was poured on a resident's face. These events involved residents with cognitive and behavioral issues and were not prevented due to lack of supervision and failure to address escalating behaviors.
A resident with diabetes and cognitive impairment was sent to a hospital following two altercations and was subsequently issued an Immediate Notice of Involuntary Discharge. Facility staff, including the administrator and DON, determined the facility could not meet the resident's needs and refused readmission after hospital treatment. The resident was not updated on their status and expressed distress about not being allowed to return, while the social services designee sought alternative placements and notified the Ombudsman. The facility's policy lacked guidance on immediate involuntary discharges, and staff acknowledged noncompliance with regulations regarding reevaluation after treatment.
A resident with a history of epilepsy did not receive the correct dosage of Lamotrigine due to pharmacy delivery issues and staff errors in medication administration. The facility failed to administer the prescribed dose on admission and subsequently gave incorrect doses, leading to the resident experiencing seizure-like activity and requiring hospital transfer. Staff interviews revealed a lack of adherence to medication administration policies.
Two residents, both severely cognitively impaired, were involved in an altercation when one attempted to sit on the other's lap in the dining area. The seated resident said 'No', prompting the other to strike them, causing injuries. Staff witnessed the incident but could not intervene in time. The aggressive resident had a history of mood problems and was care planned for potential aggression. The facility's policy failed to prevent this resident-to-resident abuse.
A facility failed to ensure the safe storage and accountability of a resident's narcotic medication, resulting in 30 missing Oxycodone tablets. RN B signed for a delivery without verifying the contents due to being busy, and the narcotic card was not found in any storage locations. The pharmacy's protocol for verifying and signing for medications was not followed.
The facility failed to maintain a comprehensive infection prevention program, ensure proper hand hygiene during wound care, and screen residents for TB according to policy. Staff did not consistently implement Enhanced Barrier Protection, and several residents lacked documented TB tests or screenings.
The facility failed to assess, identify, and provide supportive interventions for a resident diagnosed with PTSD. The resident's care plan lacked specific interventions related to PTSD, and staff were unaware of the diagnosis and potential triggers. Interviews with staff and review of medical records confirmed the deficiency.
The facility failed to maintain cleanliness and proper food safety standards, with debris in storage areas, dirty kitchen utensils, and infrequent changes of deep fryer oil. A refrigerator also lacked a thermometer, making it difficult to confirm adequate temperature ranges for food storage.
The facility failed to provide education and obtain signed consent or refusal for the pneumococcal vaccine for four residents. Interviews revealed that the ADON and DON were responsible for ensuring vaccination processes, but these were not followed for the residents in question.
The facility failed to provide education on the COVID-19 vaccine, obtain signed consent or refusal, and document the vaccination status for three residents. The ADON and DON confirmed these deficiencies, noting the absence of necessary documentation and forms for indicating consent or refusal.
The facility failed to coordinate PASARR assessments for a resident diagnosed with schizophrenia after admission. The resident's initial screening did not indicate a major mental illness, but a subsequent diagnosis should have triggered a referral for a Level II evaluation, which was not documented. Interviews revealed that staff did not follow the expected protocol for PASARR coordination.
The facility failed to complete a PASARR for a resident with depression, bipolar disorder, and dementia. Staff interviews confirmed that the PASARR was not done as required, and the facility had been without a Social Worker for about a month.
The facility failed to update comprehensive care plans for two residents, one with severe cognitive impairment and another with significant dental issues. Despite documented behaviors and conditions, these were not reflected in the care plans, leading to a lack of continuity in care.
A resident with hemiplegia and contractures did not have a prescribed hand brace applied as required. Despite a physician's order and multiple observations, staff failed to assist the resident in wearing the brace, and documentation was incomplete. Interviews revealed a lack of adherence to the care plan and physician's order.
The facility failed to accurately complete comprehensive fall investigations for a resident at risk for falls, resulting in multiple incidents without proper documentation of root cause analysis, environmental factors, or fall prevention measures. Staff were unaware of the resident's fall history and specific prevention measures, leading to incomplete and inaccurate incident reports.
The facility failed to ensure that a resident with a feeding tube and oral intake was receiving adequate nutrition by not recording oral intake and not weighing the resident regularly. Staff interviews revealed a lack of clarity on who was responsible for weighing the resident, leading to inconsistent monitoring of the resident's nutritional status.
The facility failed to maintain sanitary oxygen equipment for three residents, including improper storage, lack of water in humidifiers, and failure to change and date oxygen supplies. Staff interviews revealed inconsistencies and lack of knowledge regarding proper procedures.
The facility failed to address a pharmacy recommendation to discontinue an antipsychotic medication for a resident with Parkinson's Disease and dementia. Staff interviews revealed a lack of clear processes for documenting physician responses to pharmacy recommendations, resulting in the recommendation being missed and not addressed in a timely manner.
The facility failed to ensure that two residents received necessary dental services for broken or missing teeth and did not provide a dental consultation for another resident who had a physician order for dental extractions. Staff members were unaware of the residents' dental needs, and there was a lack of follow-up and documentation for dental appointments.
A resident's debit card and checks were misappropriated, leading to unauthorized transactions and financial loss. The facility's investigation could not identify the perpetrator, and the resident was offered a lock box for safekeeping of personal items. Staff were re-educated on policies following the incident.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition following a fall. A resident admitted for a respite stay with a history of falling and dementia was on a locked memory care unit when a staff member opened a door, startling the resident, who then fell to the floor onto the right side. The resident was non-verbal but moaned in pain when the right leg was touched, although some range of motion remained. Facility documentation shows that hospice was notified and a hospice nurse assessed the resident later that evening, noting no complaints of pain, the ability to move the leg without complaint, and no new orders. The hospice nurse indicated they would follow up and inform the resident’s family. The facility’s fall investigation and review of the electronic medical record revealed no documentation that the resident’s responsible party was notified of the fall on the day it occurred. The investigation noted that the hospice nurse stated they would notify the family, and there was no follow-up by facility staff to ensure that this notification actually occurred. Interviews with the Administrator, CMT, RN, LPN, and DON confirmed that nurses were responsible for notifying a resident’s responsible party immediately after a change in condition and that the facility remained responsible for notification even if a hospice nurse said they would notify the family. Staff and leadership acknowledged that the resident’s family was not notified by the facility on the day of the fall and that the family was notified later than expected under facility policy and practice.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, resulting in several incidents of physical aggression between residents. In one case, a resident with hemiplegia and a history of verbal aggression struck another resident in the back of the head after being called a derogatory name. Both residents involved had cognitive impairments and behavioral histories, and the altercation was preceded by verbal exchanges. Staff and administration were aware of prior verbal altercations but did not implement interventions to prevent escalation to physical abuse. Another incident involved two residents in the dining room, where one resident with dementia and a history of psychosocial issues physically assaulted another resident, causing visible injuries including a laceration and bruising. The altercation was triggered by a dispute at the lunch table, with conflicting accounts from residents and staff about the sequence of events. Staff were not present in the dining room at the time of the incident, and the response to the altercation was delayed, resulting in one resident being struck multiple times before staff intervened. A third incident occurred when a resident with a history of aggressive behavior poured hot sauce on the face of another resident with severe cognitive impairment. The event followed a pattern of playful interactions that escalated into aggression, with both residents initially engaging in mutual teasing. Staff observed the aftermath and intervened to separate the residents and provide care. In all cases, the facility's failure to adequately supervise residents, recognize escalating behaviors, and implement preventive interventions contributed to the occurrence of abuse.
Failure to Allow Resident Return After Hospitalization and Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a resident was allowed to return after being sent to a local hospital, resulting in an involuntary discharge that did not meet regulatory requirements. The resident, who had a diagnosis of Diabetes Mellitus Type II and moderately impaired cognition, was involved in two resident-to-resident altercations and was subsequently sent to the hospital. The facility issued an Immediate Notice of Involuntary Discharge, citing endangerment to the safety and health of individuals in the facility, and refused to readmit the resident after hospital treatment. Interviews with facility staff revealed that the administrator and director of nursing did not believe the facility was equipped to care for the resident and made the decision not to allow the resident back. The social services designee sent referrals to other facilities and notified the Ombudsman of the discharge. The resident expressed confusion and distress about not being allowed to return, stating that the facility was their home and they had not been updated on their situation. The facility's policy on transfers and discharges did not address immediate involuntary discharges, and staff acknowledged that regulations were not met by failing to reevaluate the resident after hospital treatment.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Lamotrigine Extended Release (ER) for seizure management. The resident, who had a history of epilepsy and was admitted to the facility from the hospital, did not receive the prescribed dose of Lamotrigine on the day of admission. The medication was not administered because it had not arrived from the pharmacy, and the staff did not utilize the available medication from the Omnicell. On subsequent days, the resident received incorrect doses of the medication. The pharmacy delivered 100 mg tablets instead of the prescribed 200 mg tablets, and the staff failed to administer the correct total dosage of 400 mg at bedtime. This error was compounded by the lack of communication with the physician to clarify the medication order or to address the discrepancy in the dosage provided by the pharmacy. Interviews with the nursing staff and the Director of Nursing revealed a breakdown in the medication administration process, including failure to verify medication orders against the medication administration record (MAR) and the medication cards. The staff did not follow the facility's policy of checking the Omnicell for available medications or notifying the physician when the correct dosage was not available. These actions and inactions led to the resident experiencing seizure-like activity and being transferred to the hospital.
Resident-to-Resident Altercation Due to Cognitive Impairment
Penalty
Summary
The facility failed to protect a resident from abuse when another resident, both of whom were severely cognitively impaired, was involved in an altercation. On the day of the incident, one resident attempted to sit on the lap of another resident who was seated in a wheelchair in the dining area. When the seated resident put up their hands and said 'No', the other resident turned around and struck them in the face, causing a scratch on the lip and a bruise over the left eye. This resulted in the resident sliding out of their wheelchair and being transported to the emergency room for evaluation. The incident was witnessed by several staff members, including CNAs and a CMT, who were unable to intervene in time to prevent the altercation. The staff members reported seeing the resident attempt to sit on the other resident's lap and then strike them when they were told 'No'. The facility's investigation determined that the resident who initiated the aggression had a history of mood problems related to a heightened startled response, which was care planned. The root cause analysis suggested that the resident reacted to being startled by the other resident's verbal refusal. Both residents involved in the incident had diagnoses of dementia and cognitive communication deficits, with the aggressive resident also having a care plan indicating potential for physical aggression. The facility's policy on abuse and neglect emphasizes that residents must not be subjected to abuse by anyone, including other residents. Despite this policy, the incident occurred, highlighting a failure to ensure the safety and protection of residents from abuse by peers.
Failure to Verify and Store Narcotic Medication
Penalty
Summary
The facility staff failed to ensure the safe storage and accountability of a resident's narcotic medication, specifically 30 tablets of Oxycodone HCL 10 mg, which were reported missing. The incident involved a failure to verify and sign for the delivery of medications to the East Nurses Station. RN B, who was responsible for receiving the medications, signed for a delivery without verifying the contents, which included the missing narcotic medication for a resident with a history of chronic pain and other significant medical conditions. RN B admitted to signing for a blue bag from the pharmacy without opening it or checking the contents due to being busy. The pharmacy's delivery manifest indicated that two narcotic medications were delivered, but RN B did not check off the medications as received. The pharmacy driver also signed the delivery receipt, but there was no documentation of the time or date of delivery. The facility's investigation revealed that the narcotic card was not found in any of the usual storage locations, and RN B was suspended pending the investigation. Interviews with other staff members highlighted the protocol for receiving and storing narcotic medications, which was not followed in this instance. The pharmacy's General Manager confirmed that controlled substances are typically delivered in a red sealed bag, and the receiving nurse is expected to verify and sign for each medication. However, in this case, the verification process was not completed, leading to the unaccounted narcotic medication.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program, which included the prevention and transmission of water-borne pathogens. The facility's water management program lacked a diagram or flowchart identifying specific potential risk areas, a facility-specific risk assessment, and a completed CDC toolkit with control measures. Additionally, there was no documented infection prevention program or plan to deal with outbreaks of Legionella and other waterborne pathogens, including testing protocols and acceptable ranges for control measures. The Maintenance Supervisor and Administrator acknowledged the deficiencies during interviews, and the in-service sign-in sheets provided lacked educational materials attached. The facility also failed to ensure proper hand hygiene and infection control practices during wound care for two residents. One resident with open wounds on the thighs did not have Enhanced Barrier Protection (EBP) in place, and the wound care nurse did not change gloves or cleanse hands between treating different wounds, leading to potential cross-contamination. Another resident with a suprapubic catheter had the catheter drainage bag touching the floor multiple times, and the nurse did not wear a gown during catheter irrigation, contrary to EBP protocols. Staff interviews confirmed that the facility had recently provided education on EBP, but the implementation was inconsistent. Furthermore, the facility did not ensure that all residents were screened for tuberculosis (TB) according to the facility policy. Several residents did not have documented two-step TB skin tests or chest x-rays upon admission, and there was no annual screening for TB symptoms. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lapses in TB screening and testing, attributing the deficiencies to incomplete orders and documentation by the nursing staff.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess, identify, and provide supportive interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's admission record indicated multiple diagnoses, including PTSD, dementia with mood disturbances, major depressive disorder, borderline personality disorder, and hemiplegia. However, the Trauma Informed Care assessment did not include any detailed information about the resident's PTSD, triggers, or events. The care plan also lacked specific interventions related to the PTSD diagnosis, and there was no documentation of psychiatric consultations or further assessments for PTSD in the resident's medical records. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and potential triggers. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) interviewed were unaware of the PTSD diagnosis and any associated triggers. The Director of Social Services and the Director of Nursing (DON) acknowledged that the care plan should have included the PTSD diagnosis, triggers, and interventions, and that staff should have been informed about the resident's PTSD status. The deficiency was identified as a failure to provide trauma-informed care as per the facility's policy.
Failure to Maintain Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in the kitchen and food storage areas. Observations revealed that the dry storage room and walk-in freezer floors were littered with various debris, including plastic, paper, and food packets. The manual can opener had an unknown residue on its blade, and several cutting boards were excessively scored, posing a risk of cross-contamination. Additionally, the deep fryer oil was not changed frequently enough, resulting in oil that was black and filled with crumbs. A white-handled spatula was found with chipped edges, further indicating poor maintenance of kitchen utensils. During inspections, it was also noted that a refrigerator in the galley between the locked unit dining room and the rehab unit dining room lacked a thermometer, making it difficult to confirm adequate temperature ranges for food storage. Interviews with the Dietary Services Manager (DSM) and the Administrator confirmed these deficiencies, with the DSM acknowledging that the deep fryer oil was changed only every other week and that all refrigerators should have thermometers. Despite these acknowledgments, follow-up inspections showed that the issues persisted, with the deep fryer oil remaining in poor condition and debris still present in the storage areas.
Failure to Provide Pneumococcal Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide education to residents or their representatives and obtain signed consent or refusal for the pneumococcal vaccine for four residents. Specifically, two residents had no evidence of being offered or administered the vaccine, nor any signed consent or refusal documented. Another resident had a status of consent refused for the vaccine but lacked a signed refusal form. Additionally, one resident had verbally consented to the vaccine, but there was no evidence of education provided or the vaccine being administered. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the ADON was responsible for ensuring the completion of pneumococcal vaccinations, including reviewing vaccine history on admission and offering the vaccine to residents. The DON confirmed that the ADON was tasked with infection control and ensuring the completion of vaccinations, while the DON was ultimately responsible for ensuring education, obtaining signed consents/refusals, administering the vaccine, and documenting the vaccination status in the medical records. However, these processes were not followed for the residents in question.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide education on the COVID-19 vaccine, obtain signed consent or refusal, and document the vaccination status for three residents out of five sampled residents. Specifically, Residents #48, #61, and #166 had no evidence in their medical records of COVID-19 vaccination history, education provided, or signed consent or refusal forms. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed these deficiencies during interviews, noting that the facility did not have a form for residents to sign indicating consent or refusal for the COVID-19 vaccine. The ADON was responsible for ensuring the completion of COVID-19 vaccinations for residents, including reviewing vaccine history on admission and offering the vaccine to residents or their medical representatives. Despite these responsibilities, the facility failed to document the necessary information in the medical records of the affected residents. The DON acknowledged that the ultimate responsibility for ensuring residents received education, signed consents, and proper documentation of vaccination status rested with the facility's administration.
Failure to Coordinate PASARR Assessments for Resident with New Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident with a newly diagnosed mental disorder. Specifically, the facility did not refer Resident #48, who was diagnosed with schizophrenia after admission, for a Level II PASARR evaluation. The resident's initial Level One screening did not indicate a major mental illness, but a subsequent diagnosis of schizophrenia was made, which should have triggered a referral to the appropriate state-designated mental health authority for further review. However, there was no documentation of such a referral or evaluation in the resident's medical record. Interviews with the Social Services Director and the Regional Director of Nursing revealed that the facility's staff did not follow the expected protocol for PASARR coordination. The Social Services Director acknowledged that an evaluation should have been completed following the new diagnosis to ensure the resident's needs could be met by the facility. The Regional Director of Nursing confirmed that the facility social worker was responsible for PASARR coordination and should have conducted a follow-up after the new diagnosis of schizophrenia. This oversight resulted in a failure to comply with federal requirements for appropriate placement and care of residents with mental impairments.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for one resident out of 23 sampled residents. The resident, who had diagnoses of depression, bipolar disorder, and dementia, was admitted to the facility without a Level I PASARR being completed. The facility's policy mandates that a PASARR should be completed prior to admission, but this was not done for the resident in question. The resident's medical record showed no documentation of a Level I PASARR, and interviews with staff confirmed that the PASARR was not completed as required. The Social Service Director and Social Service Assistant both acknowledged that the PASARR for the resident was not done and should have been completed within 72 hours of admission. The Director of Nursing (DON) also confirmed that the PASARR should have been completed at the time of admission and that the Social Worker was responsible for ensuring its completion. The facility had been without a Social Worker for about a month, and the MDS Coordinator was assisting in ensuring all residents had a PASARR. However, this particular resident's PASARR was missed.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to provide continuity of resident care by not reviewing and revising comprehensive care plans for two residents. Resident #114, who was severely cognitively impaired, exhibited multiple instances of refusing care, medication, and food. Despite these behaviors being documented in progress notes, they were not reflected in the resident's care plan. Interviews with staff revealed that behaviors were reported and documented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR), but the care plan was not updated accordingly. The Director of Nursing confirmed that these refusals should have been documented in the care plan. Resident #9 had broken teeth and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). Despite the resident's dental issues being noted during an admission assessment and a subsequent dental visit, these issues were not included in the resident's care plan. Interviews with various staff members, including a Certified Nursing Assistant (CNA), Certified Medication Technician (CMT), Registered Nurse (RN), and Social Service Assistant (SSA), revealed a lack of awareness about the resident's dental issues and confirmed that these should have been documented in the care plan. The Director of Nursing acknowledged that both residents' care plans should have been updated to reflect their current needs and issues. The facility's policy required comprehensive care plans to be updated periodically and with each Minimum Data Set (MDS) assessment. The failure to update the care plans resulted in a lack of continuity in resident care, as the care plans did not accurately reflect the residents' current conditions and needs.
Failure to Apply Prescribed Hand Brace
Penalty
Summary
The facility failed to ensure that staff applied a brace to a resident's hand as prescribed. Resident #13, who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and contractures, had a physician's order for a splint/brace to be applied to the left hand for six to eight hours daily. Despite this order, multiple observations over several days showed that the resident was not wearing the brace, and interviews with the resident and staff confirmed that the brace was not being applied as required. The resident reported being unable to put the brace on independently and stated that staff had not assisted despite requests. Interviews with various staff members, including CNAs, RNs, and the Director of Nursing, revealed a lack of awareness and adherence to the physician's order. Staff members admitted they had not seen the resident with the brace on and acknowledged that it should have been applied during morning care. Documentation in the Treatment Administration Record (TAR) was incomplete, with no records indicating that the brace had been applied or removed, only assessments of pain and skin integrity. The Director of Nursing and other staff members confirmed that the responsibility for ensuring the brace was applied fell on the CNAs, RAs, and ultimately the Charge Nurse. However, the failure to document and follow through with the physician's order resulted in the resident not receiving the necessary treatment to manage their condition effectively.
Failure to Complete Comprehensive Fall Investigations
Penalty
Summary
The facility failed to accurately complete comprehensive fall investigations for a resident at risk for falls. The resident, diagnosed with dementia and severe cognitive impairment, experienced multiple falls, including an unwitnessed fall that resulted in a head injury. The facility's documentation lacked details on the root cause analysis, environmental factors, and fall prevention measures in place at the time of the incidents. On one occasion, the resident fell out of bed and was sent to the hospital for evaluation. Upon return, no new preventative fall interventions were documented. Another fall occurred, and the incident report did not include comprehensive details such as the resident's positioning, the bed's position, or the presence of fall mats. Interviews with staff revealed a lack of awareness of the resident's fall history and the specific fall prevention measures required. The facility's fall management policy was not followed, as evidenced by incomplete and inaccurate incident reports and a lack of detailed investigations. The Director of Nursing and other staff members acknowledged the deficiencies in the fall investigation process, including the absence of a detailed root cause analysis and follow-up documentation.
Failure to Ensure Adequate Nutrition and Regular Weighing of Resident
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube and oral intake was receiving adequate nutrition by not recording the amount of food taken orally and not weighing the resident regularly. The resident, who had diagnoses including gastrostomy status, anoxic brain damage, autistic disorder, and dysphagia, was admitted with specific dietary and feeding instructions. However, there was no physician's order or care plan documentation specifying the frequency of weighing the resident, and the last recorded weight was on 4/9/24, despite the resident being on tube feedings and requiring regular monitoring of nutritional status. Interviews with facility staff, including a CNA, CMT, RN, and the DON, revealed a lack of clarity and communication regarding who was responsible for weighing the resident. The staff indicated that the Restorative Aide was typically responsible for weighing residents, but this individual had been sick, and there was no clear protocol for ensuring that other staff members took over this responsibility. The staff also confirmed that the resident should have been weighed weekly, but this was not consistently documented or communicated. The facility's policy required consistent methods for weighing residents and monitoring their nutritional status, but these procedures were not followed for the resident in question. The lack of documentation and clear responsibility led to the resident not being weighed regularly, which could have impacted their nutritional management and overall health status. The deficiency highlights a breakdown in communication and adherence to established protocols within the facility.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to ensure that oxygen equipment for three residents was stored and maintained in a sanitary condition. Resident #5's oxygen humidifier had less than 1/4 inch of water, was not dated, and the oxygen tubing was not dated. The nebulizer mask was left on the bedside tray table without a bag or date. The resident was unaware of when the tubing was last changed, estimating it had been a couple of weeks. Resident #9's oxygen humidifier was empty, and the water container was not dated. The CPAP mask was in a bag dated 4/18/24, and the resident reported that staff did not regularly change the oxygen supplies or assist with the CPAP mask at night. Observations on 5/3/24 confirmed the humidifier was still empty, and the CPAP mask remained in the same dated bag. Resident #51's oxygen tubing was dirty and improperly stored, with the humidifier also lacking water. The tubing was observed on a bloody incontinent pad, and the resident indicated that the tubing was changed infrequently, possibly monthly. The wound care nurse confirmed the improper storage and changed the tubing but did not date the new water container. Interviews with staff revealed a lack of knowledge and consistency in changing and dating oxygen supplies, with the Director of Nursing acknowledging the deficiencies and attributing them to missed responsibilities by the night shift charge nurse.
Failure to Address Pharmacy Recommendation in a Timely Manner
Penalty
Summary
The facility failed to address the pharmacy's recommendation to the physician in a timely manner for one resident. The resident, who had been diagnosed with Parkinson's Disease and dementia, was on three medications for Parkinson's. The pharmacy recommended discontinuing Nuplacid, an antipsychotic medication, but there was no documentation from the physician responding to this recommendation. Interviews with various staff members, including RNs, LPNs, the ADON, and the DON, revealed that there was no clear process for documenting the physician's response to pharmacy recommendations, especially when the physician disagreed with the recommendation. The DON admitted that the recommendation was missed and not addressed in a timely manner. The facility's policy required that the pharmacist's recommendations be addressed by the attending physician, Medical Director, and DON, and that any actions or rejections be documented in the resident's health record. However, in this case, the policy was not followed, and there was no documentation of the physician's decision regarding the pharmacy's recommendation. The staff interviews indicated a lack of clarity and consistency in handling and documenting pharmacy recommendations, leading to the deficiency in addressing the resident's medication regimen review in a timely manner.
Failure to Provide Necessary Dental Services and Consultations
Penalty
Summary
The facility failed to ensure that two residents received necessary dental services for broken or missing teeth and did not provide a dental consultation for another resident who had a physician order for dental extractions. Resident #9 had broken teeth and was at risk for malnutrition. Despite a dental visit recommending extractions and dentures, there was no follow-up appointment scheduled, and the resident expressed frustration about the delay. Staff members were unaware of the resident's dental issues, and there was no documentation of a scheduled appointment for the extractions. Resident #13 had missing teeth and dentures upon admission but lost the dentures while at the facility. The resident expressed a desire for new dentures, but there was no documentation of a dental visit or follow-up. Staff members were unaware of the resident's dental needs, and the Social Services department failed to ensure the resident saw a dentist. The resident's care plan did not address the dental issues, and there was no annual assessment to determine the need for dentures. Resident #27 had multiple missing and broken teeth and a physician order for a referral to an oral surgeon for extractions. Despite the order, there was no progress in scheduling the appointment, and the resident had not received an update. The Social Services department and the Assistant Director of Nursing were both involved in the process but failed to coordinate effectively, resulting in a lack of follow-up and documentation. The Director of Nursing acknowledged the responsibility of the Social Services department to make dental appointments and the need for proper documentation.
Failure to Protect Resident's Belongings
Penalty
Summary
The facility failed to protect a resident's belongings, resulting in the misappropriation of the resident's debit card and checks. The resident, who had a history of memory deficit following a stroke, bilateral hearing loss, and depression, reported the missing items on 10/12/23. The facility's Social Service Assistant (SSA) and Director of Nursing (DON) initiated an investigation and found the checkbook but not the debit card. Unauthorized transactions were identified, including a declined purchase of $11.60, a $60.00 gas bill payment, and two checks cashed for $875.00 and $1000.00, respectively. The resident did not authorize these transactions and was unaware of who took the items. The facility's investigation revealed that the resident's debit card was used without authorization on multiple occasions, and the checks were cashed with forged signatures. The police were notified, and a report was filed on 10/12/23. The SSA assisted the resident in contacting the bank to cancel the debit card and close the compromised account. The bank confirmed the fraudulent transactions and provided copies of the cashed checks, which were not signed by the resident. The facility interviewed relevant staff and the resident but could not identify the perpetrator. The resident was offered a lock box for safekeeping of personal items, and the bank refunded the stolen money. Despite these measures, the facility's failure to protect the resident's belongings led to significant financial loss and distress for the resident. The facility's policies on abuse, neglect, and misappropriation of resident property were reviewed, and staff were re-educated on these policies following the incident.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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