Milan Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milan, Missouri.
- Location
- 52435 Infirmary Road, Milan, Missouri 63556
- CMS Provider Number
- 265238
- Inspections on file
- 24
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Milan Health Care Center during CMS and state inspections, most recent first.
Two residents, one with cognitive impairment and another with a history of mental health conditions, were subjected to non-consensual sexual contact by another resident with moderately impaired cognition. The incidents involved inappropriate touching and exposure, with both victims displaying distress and fear following the events. Staff and care plans did not adequately address or monitor the perpetrator's behaviors, nor did they provide sufficient supervision to prevent these incidents.
The facility did not provide a full-time DON who was not also serving as a charge nurse when the census was over 60, as required by policy. Staffing records and staff interviews confirmed that on several days, there was no DON coverage due to staff shortages and the interim administrator's absence.
The facility did not maintain adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A resident with a history of mental illness and behavioral symptoms was physically assaulted by another resident with dementia and mood disturbances, despite care plans and behavior monitoring intended to prevent such incidents. The aggressor had previously exhibited hostile behavior and targeted the victim, but staff interventions were not effective in preventing the altercation in the smoking area.
The facility failed to provide a full-time DON who did not serve as a charge nurse, despite having a census over 60 residents. The DON frequently worked as a charge nurse, violating facility policy and federal regulations. Additionally, the facility did not maintain eight consecutive hours of RN staffing on at least two occasions. Interviews revealed staffing challenges, with the DON unable to fulfill administrative duties due to working as a charge nurse.
The facility failed to maintain clean and intact ceilings in food-related areas, risking contamination. Moisture damage, flaking paint, and dust buildup were observed. Additionally, the ice machine lacked a proper air gap, posing a contamination risk. Staff were unaware of these issues, indicating lapses in oversight.
The facility failed to complete required Significant Change in Status Assessments (SCSA) for four residents after significant changes in their conditions, including cognitive decline, new diagnoses, changes in ADLs, and hospice enrollment. The MDS Coordinator was not informed of these changes due to a lack of communication, leading to non-compliance with federal regulations.
The facility failed to accurately code the MDS for four residents, resulting in discrepancies in their assessments. Inaccuracies included cognitive status, preferences, and functional limitations, with residents marked as rarely/never understood despite being alert and oriented. The MDS/Care Plan Coordinator noted past coding issues and a lack of formal training, while the Activity Director reported challenges due to frequent coordinator changes and technical issues. The Administrator expected accurate MDS completion but noted staff were not consistently conducting resident interviews.
The facility failed to update care plans for several residents, leading to deficiencies in care. One resident experienced a decline in cognitive and physical abilities, including a new pressure ulcer and colostomy, without care plan updates. Another resident's care plan lacked documentation for a PICC line used for IV antibiotics. A third resident's care plan did not reflect changes in communication and ADL needs, while a fourth resident's care plan inaccurately documented oxygen therapy and ADL independence.
The facility failed to provide adequate ADL care and hygiene for several residents, as evidenced by inconsistent shower schedules and improper perineal care. Residents were not receiving regular showers, and staff did not perform complete perineal care during incontinence episodes. Documentation was incomplete, and staffing shortages contributed to these deficiencies. The Director of Nursing and Administrator acknowledged the issues but had no plan in place to address them.
The facility failed to provide adequate nursing staff, resulting in missed showers and restorative care for residents. Observations showed residents with poor hygiene and worsening contractures due to insufficient care. Staffing levels were consistently below required numbers, with the DON and department heads covering nursing roles. The facility had previously used agency staff but was not allowed to do so at the time.
The facility failed to ensure meals were served at safe and appetizing temperatures, as required by policy. Observations and interviews revealed that several residents received meals that were not hot enough, with food temperatures not consistently checked during service. The Dietary Manager admitted that the cook did not always monitor temperatures, leading to meals being served outside the acceptable range.
The facility failed to ensure proper hand hygiene and glove use, leading to deficiencies in infection control. Staff did not wash hands between glove changes or sanitize soiled surfaces properly. Respiratory equipment was improperly stored, and medication administration lacked adherence to hygiene protocols. These actions indicate systemic issues with infection control policies.
The facility failed to accommodate the needs of two residents requiring power wheelchairs for independence. One resident, a paraplegic, was denied a power wheelchair despite having a physician's order and Medicaid approval, leaving them dependent on staff. Another resident with multiple sclerosis faced threats of having their motorized chair taken away, despite no documented safety concerns. The administrator's personal preference against motorized chairs led to these denials, contradicting the facility's policy on assistive devices.
The facility failed to provide adequate restorative nursing services to two residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. Resident #30, who is paraplegic, and Resident #55, who has severe cognitive impairment, both required passive range of motion exercises. However, the facility's records showed inconsistent documentation and a lack of comprehensive restorative plans. Interviews revealed that staffing shortages led to the restorative aide being frequently pulled to work as a CNA, contributing to the lack of consistent care.
A facility failed to prevent residents from accessing fire-starting materials, resulting in two fire incidents in a shared room. Staff detected a fire in the bathroom trash can, which a resident extinguished, but later a second fire occurred in a box on one resident's side. The residents had significant medical and behavioral histories, including schizophrenia and COPD, and were listed as unsupervised smokers despite care plans indicating the need for supervision. Staff interviews revealed lapses in monitoring and enforcement of the smoking contraband policy.
The facility failed to report an alleged sexual abuse incident involving two residents to the state agency. A nurse aide found a resident in another's room, leading to concerns of sexual activity. Despite staff reporting the incident to an LPN and the ADON, it was not reported to the state agency as required. The residents involved had diagnoses of dementia and Alzheimer's disease.
The facility failed to investigate an alleged sexual abuse incident between two residents. Despite staff concerns, the LPN and ADON dismissed the situation as exaggerated and did not conduct necessary interviews with other residents or staff. The Director of Nursing and Administrator were unaware of the incident's seriousness, resulting in a deficiency in addressing the alleged abuse.
A resident with impaired cognition and mobility needs was not safely secured in a transport van, leading to an accident. The resident slid out of the wheelchair due to unsecured front wheels and an improperly positioned seatbelt. The incident resulted in minor injuries and a hospital evaluation, revealing no acute injuries but existing degenerative spondylosis.
The facility failed to protect two residents from sexual abuse by not assessing their capacity to consent to sexual activity. Both residents had cognitive impairments and legal guardians, with one having a history of hypersexual behavior. Staff observed inappropriate behaviors but did not implement specific interventions until after the residents were found naked in bed together.
The facility failed to thoroughly investigate an allegation of sexual abuse between two residents, neglecting to interview other residents and all staff present. Both residents had histories of cognitive impairment and inappropriate behavior. The DON was aware of escalating behavior but did not implement specific interventions.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, resulting in two separate incidents involving non-consensual sexual contact. In the first incident, a resident with a history of bipolar disorder, anxiety, and major depressive disorder, who was cognitively intact, reported that another resident with moderately impaired cognition grabbed their breast without consent while they were outside in the courtyard. The victim expressed fear of being alone and of further encounters with the perpetrator. The incident was witnessed by another resident, and the victim was visibly distressed when recounting the event. Approximately four hours after the first incident was reported, staff discovered another resident, who had dementia and impaired cognition, in the perpetrator's room. This resident was found sitting on the bed with their shirt pulled up, exposing their breasts, and their pants were on inside out. The resident was distraught and tearful, refused to return to their room, and instead stayed in the common area overnight. Staff interviews and documentation confirmed that this resident required moderate to maximal assistance with activities of daily living and had no prior behaviors of wandering or entering other residents' rooms. The facility's records and staff interviews revealed that the perpetrator had previously made inappropriate sexual comments and advances toward other residents, including discussing sexually explicit material and making repeated requests for relationships despite being told no. The care plans for the involved residents did not address these behaviors or provide adequate interventions to prevent such incidents. Staff were not monitoring the perpetrator closely enough after the initial report of abuse, and there was a lack of supervision for the cognitively impaired resident who was later found in the perpetrator's room. These failures led to both residents being subjected to non-consensual sexual contact.
Failure to Provide Full-Time DON Coverage When Census Exceeded 60
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse when the facility census exceeded 60 residents, with the census documented at 86 and 87 on the affected dates. Review of staffing sheets revealed that there was no DON coverage on multiple dates in June 2025. Interviews with the DON and administrator confirmed that the DON had been reassigned to charge nurse duties due to staffing shortages, and the interim administrator, who was acting as DON, was absent from the facility for several days, resulting in no DON coverage during those times. The facility's own policy required a full-time DON, and this requirement was not met on the specified dates.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that the required staffing levels and licensed nurse coverage were not consistently maintained as mandated.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with a history of encephalopathy, bipolar II disorder, schizoaffective disorder, and anxiety disorder, who was at risk for aggression and behavioral symptoms, including wandering and verbal aggression. The care plan for this resident included interventions to avoid confrontation and to intervene as necessary to protect the safety of others. Despite these measures, the resident was physically assaulted by another resident who struck them multiple times in the face. The resident who committed the assault had diagnoses of generalized anxiety disorder, major depressive disorder, and dementia, and was noted to have impaired thought processes and mood disturbances with agitation. Prior to the incident, this resident had exhibited aggressive and hostile behaviors, including yelling, using profanity, and threatening others. Behavior monitoring and increased assessment were implemented, but staff were unable to redirect the resident effectively during behavioral crises. On the day of the incident, the resident admitted to hitting the other resident after a confrontation in the smoking area. Interviews with staff and other residents revealed that the aggressor had a history of targeting the victim and had previously intervened in altercations involving the victim and other residents. Staff were aware of the behavioral issues and previous incidents but did not anticipate the physical altercation. The facility's abuse and neglect policy required identification and intervention for residents at risk of abuse or with behaviors that could lead to conflict, but these measures were insufficient to prevent the incident.
Staffing Deficiencies and DON Role Mismanagement
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse, despite having a census over 60 residents. The facility's policy required a full-time DON and stipulated that the DON could only serve as a charge nurse when the facility's average daily occupancy was 60 or fewer residents. However, the facility's staffing sheets revealed that the DON frequently worked as a charge nurse, even when the census was as high as 98. This was a clear violation of the facility's policy and federal regulations. Additionally, the facility did not maintain eight consecutive hours of Registered Nurse (RN) staffing daily on at least two occasions. On January 11 and 12, 2025, the staffing sheets showed no RN coverage for eight consecutive hours, which is a requirement for the facility. The facility's assessment indicated that federal regulations required 3.48 hours per resident day of direct care, with 0.55 hours from RNs, but the facility failed to meet this requirement on those days. Interviews with the DON and the administrator revealed that the facility had been struggling with staffing issues. The DON reported working almost every day as a charge nurse and being unable to fulfill her administrative duties. The facility had previously relied on agency staff to fill charge nurse roles, but this practice stopped on January 1, 2025. The administrator confirmed that the DON worked the floor most of February and was only able to perform her DON role for two days that month. The Regional Director of Operations acknowledged the staffing challenges and mentioned the possibility of bringing agency staff back to the facility.
Ceiling Maintenance and Ice Machine Drain Deficiencies
Penalty
Summary
The facility failed to maintain the cleanliness and condition of ceilings in critical areas such as the dishwasher room, dry food storage room, and above food preparation and serving areas, which could potentially lead to food contamination. Observations revealed moisture damage and dark stains on the ceiling in the dry food storage room, cracked and flaking paint in the dishwasher room, and dust and debris buildup around ceiling vents above the steam table. The Dietary Manager was unaware of these issues, and the Maintenance Director acknowledged the problem but indicated that the maintenance department was responsible for repairs and cleaning, which were not being conducted as frequently as needed. Additionally, the facility did not maintain a proper air gap for the ice machine drain in the dining room, which could lead to contamination. The ice machine's drain pipes extended below the flood rim level of the floor drain, lacking the necessary air gap. The Maintenance Supervisor was unaware of this deficiency, and the Administrator expected the ice machine to have an air gap and the kitchen ceilings to be clean and well-maintained, indicating a lapse in oversight and adherence to facility policies.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for four residents following significant changes in their conditions. The SCSA is a federally mandated assessment tool that must be completed within 14 days after a significant change in a resident's condition is identified. This failure was identified during a review of 24 sampled residents, where four residents experienced significant changes in their health status, including cognitive decline, new diagnoses, changes in activities of daily living (ADLs), and enrollment in hospice care, without the required SCSA being completed. Resident #18 experienced a decline in cognitive function, new diagnoses including pneumonia and a Stage III pressure ulcer, and a decline in ADLs, yet no SCSA was completed. Resident #36 had new delusions, a new diagnosis of bipolar disorder, increased incontinence, significant weight loss, and new IV access, but the facility did not complete an SCSA. Resident #59 had a new diagnosis of pneumonia, cognitive decline, increased pain, significant weight loss, and was placed on hospice care, but the SCSA was not completed within the required timeframe. Resident #79 was admitted to hospice care, but the facility failed to complete the SCSA within 14 days of the hospice start date. The MDS Coordinator, responsible for completing these assessments, was not informed of the hospice admission due to a lack of communication, as daily nursing meetings were not occurring. This lack of communication and oversight led to the failure to complete the necessary assessments, resulting in a deficiency in the facility's compliance with federal regulations.
Inaccurate MDS Coding Leads to Assessment Discrepancies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies in their assessments. The MDS, a federally mandated assessment tool, was not completed in accordance with the Resident Assessment Instrument (RAI) manual. This resulted in inaccurate reflections of the residents' cognitive status, preferences, and functional limitations. For instance, Resident #30 was marked as rarely/never understood in some sections, despite being alert and oriented during an interview. Similarly, Resident #33, who had severe cognitive impairment, was marked as somewhat important for all preferences, although the resident was unable to consistently answer questions. Resident #36's MDS indicated cognitive intactness, but the resident had multiple diagnoses, including dementia and traumatic brain injury, which could affect cognitive function. The resident's preferences were marked as somewhat important, despite expressing differing interests during an interview. Resident #71's MDS showed inconsistencies in functional limitations and hospice status, with no documentation to support significant changes. The resident was observed with visible limitations in range of motion, contradicting the MDS entries. The facility's MDS/Care Plan Coordinator acknowledged issues with past MDS coding and noted a lack of formal MDS training. The Activity Director also reported challenges with MDS completion due to frequent changes in MDS coordinators and technical issues with data transfer. The Administrator expected accurate MDS completion but noted that staff were not consistently leaving their offices to conduct resident interviews, contributing to the inaccuracies.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs of four residents, leading to deficiencies in their care. Resident #18 experienced a significant decline in cognitive and physical abilities, including the development of a Stage III pressure ulcer, a new urinary catheter, and a colostomy following hospitalization. Despite these changes, the resident's care plan was not updated to reflect the new conditions and care requirements, such as the need for mechanical transfer and increased assistance with activities of daily living (ADLs). Resident #25's care plan did not address the presence or care of a peripherally inserted central catheter (PICC) line, despite the resident receiving intravenous antibiotics for a wound through the PICC line. The resident's quarterly Minimum Data Set (MDS) indicated the use of intravenous access and medications, yet the care plan lacked documentation of these critical medical interventions. Resident #33's care plan was outdated and did not reflect changes in the resident's communication abilities, ADL assistance needs, and ambulatory status. Observations showed the resident with disheveled hair, unshaven, and wearing wet clothing, indicating inadequate personal hygiene care. Similarly, Resident #54's care plan was not updated to reflect changes in oxygen therapy requirements and the need for assistance with ADLs following hospitalization. The care plan inaccurately documented the resident's independence in ADLs and did not address the correct oxygen settings or the use of a BiPAP machine.
Deficiencies in ADL Care and Hygiene Practices
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) to six residents who were unable to perform these tasks independently. Observations and interviews revealed that residents were not receiving necessary personal hygiene care, including regular showers and proper perineal care. For instance, one resident was observed to have not received a shower for 21 days, despite being scheduled for two showers per week. Another resident was found with greasy hair and flaky skin, indicating a lack of regular bathing. Additionally, staff failed to perform complete perineal care during incontinence episodes, as evidenced by the use of only toilet paper instead of soap and water or appropriate peri-care products. The facility's documentation was inconsistent and incomplete, with several instances where there was no record of showers being offered or refused. Residents expressed dissatisfaction with the frequency and timing of showers, and some reported feeling frustrated due to the lack of control over their personal care schedules. Staff interviews confirmed that there were not enough personnel to meet the scheduled shower requirements, and department heads were not assisting with showers as expected. This lack of staffing and support contributed to the failure to provide adequate ADL care. Furthermore, the facility's policies on incontinence care and shower schedules were not consistently followed. Residents were found wearing double incontinence products, which is against facility policy, and were not being checked and changed every two hours as required. The Director of Nursing and the Administrator acknowledged these deficiencies, noting that recent staffing shortages had impacted the ability to provide the necessary care. Despite these acknowledgments, the facility did not have a plan in place to address these issues at the time of the report.
Inadequate Staffing Leads to Missed Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the lack of routine showers and restorative nursing care for several residents. Observations and interviews revealed that residents were not receiving scheduled showers, leading to poor personal hygiene. For instance, one resident, who was dependent on staff for showers due to paraplegia, only received one shower in February and none in early March, despite being scheduled for two showers per week. Another resident with severe cognitive impairment received only two out of eight scheduled showers over a month-long period, with no documentation of refusals. Additionally, the facility did not provide adequate restorative nursing care to prevent the decline in residents' activities of daily living and worsening contractures. One resident with paraplegia and contractures was supposed to receive passive range of motion (PROM) exercises three times a week but reported receiving them sporadically, sometimes going weeks without any restorative care. The resident expressed concerns about worsening contractures and increased spasms due to the lack of consistent care. Another resident with severe cognitive impairment and functional limitations in range of motion was scheduled for daily PROM but had numerous gaps in the documentation, indicating missed sessions. The facility's staffing levels were consistently below the required numbers to meet residents' needs, as documented in the facility's staffing sheets. The Director of Nursing (DON) and other department heads often had to cover nursing roles due to staff shortages. The facility had previously used agency staff to fill gaps but was not allowed to do so at the time of the report. Interviews with the DON and other staff confirmed the ongoing staffing challenges, which directly impacted the facility's ability to provide necessary care to residents.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring and serving of food at safe and appetizing temperatures, resulting in a deficiency. Observations and interviews revealed that residents frequently received meals that were not served at the appropriate temperatures. Several residents reported that their meals were often cold or not hot enough, whether they ate in the dining room or in their rooms. The facility's policy required staff to record food temperatures at the beginning and during the tray line service, and to reheat or chill food items if they did not meet acceptable serving temperatures. However, staff did not consistently check food temperatures during meal service, as evidenced by the test tray showing the tuna noodle casserole at 118.2 degrees Fahrenheit and the tossed salad at 77.0 degrees Fahrenheit, both outside the acceptable temperature range. The Dietary Manager acknowledged that the cook did not always check food temperatures midway through meal service, and the Administrator confirmed the expectation for hot foods to be served hot and cold foods to be served cold. Despite the initial cooking temperatures being within acceptable parameters, the failure to monitor and maintain these temperatures during service led to the deficiency. The facility census was 98, and the issue affected multiple residents, as indicated by their complaints about the temperature of their meals.
Infection Control Deficiencies in Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use among nursing staff, leading to multiple deficiencies in infection prevention and control. Observations revealed that staff did not wash their hands after direct resident contact and between glove changes. For instance, a nurse assistant was observed handling soiled incontinence briefs and cleaning feces from surfaces without changing gloves or washing hands. This practice was repeated across different residents, with staff failing to perform hand hygiene before and after glove use, and touching clean surfaces with soiled gloves. Additionally, the facility did not ensure that soiled surfaces were sanitized appropriately. A nurse assistant was observed using perineal wipes to clean feces from surfaces, unaware of the need to use a disinfectant. This lack of proper sanitation was compounded by the improper handling of respiratory care supplies. A resident's BiPAP and nebulizer equipment were found unbagged and improperly stored, with the BiPAP mask even touching the floor, which was not addressed by the staff. Furthermore, the facility failed to adhere to infection control protocols during medication administration. A registered nurse was observed administering insulin without performing hand hygiene between glove changes and after handling the glucometer. Similarly, a certified medication technician administered eye drops without wearing gloves. These actions indicate a systemic issue with adherence to infection control policies, as confirmed by interviews with staff who acknowledged the lapses in hand hygiene and glove use.
Facility Fails to Accommodate Residents' Need for Power Wheelchairs
Penalty
Summary
The facility failed to accommodate the needs and preferences of residents requiring power wheelchairs for independence, as evidenced by the experiences of two residents. Resident #30, who is paraplegic and cognitively intact, was denied assistance in obtaining a power wheelchair despite having a physician's order and Medicaid approval. The facility administrator forbade power chairs, citing safety concerns, and suggested the resident move to another facility. This decision left Resident #30 feeling hopeless, discriminated against, and dependent on staff for mobility, as the resident was confined to a geri chair that required staff assistance for movement. Resident #11, who uses a motorized chair due to multiple sclerosis and is cognitively intact, faced threats from the administrator to have their chair taken away. The resident's medical records showed no documented safety concerns or incidents of running into others, contrary to the administrator's claims. The resident's driving assessment indicated they could drive with some difficulty, but no specific pass or fail criteria were noted. The lack of mirrors and speed adjustments recommended in the assessment were not addressed, and the resident expressed concerns about losing independence and becoming more depressed without the chair. The facility's policy on the use of assistive devices emphasizes the importance of providing necessary equipment to maintain or improve residents' function and dignity. However, the administrator's actions contradicted this policy by preventing residents from using power wheelchairs, which are essential for their independence. The therapy director confirmed that the residents were eligible for power chairs and that therapy could assist in ensuring safe use, but the administrator's personal preference against motorized chairs led to the denial of these necessary accommodations.
Inadequate Restorative Nursing Services for Residents
Penalty
Summary
The facility failed to provide adequate restorative nursing services to two residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. The facility did not adhere to its policy of developing comprehensive restorative plans that include specific interventions, measurable goals, and documentation of the services provided. This failure was observed in the cases of two residents, both of whom had significant physical impairments requiring restorative care. Resident #30, who is paraplegic and uses a gerichair for mobility, was supposed to receive passive range of motion (PROM) exercises as part of their care plan. However, the facility's records showed inconsistent documentation of these exercises, with no clear indication of the frequency, duration, or specific goals of the interventions. The resident reported experiencing increased spasms and worsening contractures, indicating a lack of consistent restorative care. The facility's documentation did not reflect any refusals of care by the resident, suggesting that the services were simply not provided as required. Similarly, Resident #55, who has severe cognitive impairment and functional limitations due to a stroke, was also supposed to receive daily PROM exercises. The facility's records showed numerous gaps in the documentation of these exercises, with no evidence of refusals by the resident. The facility failed to maintain a restorative plan of care that included specific interventions and goals, and there was no documentation of regular evaluations by the Restorative Nurse. Interviews with staff revealed that the restorative aide was frequently pulled to work as a CNA due to staffing shortages, which contributed to the lack of consistent restorative care for the residents.
Failure to Prevent Fire Hazards in Resident Room
Penalty
Summary
The facility failed to provide protective oversight to prevent residents from having materials to start a fire, leading to two fire incidents in a shared room. On the first occasion, staff detected an odor and discovered a small fire in the bathroom trash can, which a resident claimed to have extinguished with water. Despite a search, no lighter was found, but cigarettes and ashes were discovered in the room. Shortly after, a second fire occurred, originating from a box on one resident's side of the room, prompting a Code Red and evacuation of residents. The residents involved had significant medical and behavioral histories. One resident had diagnoses including depression, schizophrenia, and mild cognitive impairment, with a care plan indicating a need for supervision while smoking. The other resident had paranoid schizophrenia and COPD, with a history of hiding lighters and saving cigarette butts. Despite these risks, both residents were listed as unsupervised smokers, contrary to their care plans and smoking safety evaluations. Interviews with staff revealed lapses in monitoring and enforcement of the facility's smoking contraband policy. Staff were aware of the residents' tendencies to sneak cigarette butts and lighters but failed to maintain adequate supervision or conduct thorough searches. The facility's policy required residents to turn in smoking materials, but this was not effectively enforced, contributing to the incidents.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the state agency. The incident occurred when a nurse aide entered a resident's room and found another resident standing beside the bed, zipping up their pants. The staff involved reported the incident to a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), but the ADON did not instruct the LPN to report the incident to the state agency, believing the situation was exaggerated. Resident #1, who was involved in the incident, had a diagnosis of unspecified dementia and bipolar disorder, and was noted to have communication problems related to dementia. Resident #2, who was new to the facility, had a diagnosis of early onset Alzheimer's disease and dementia. Despite the concerns raised by the staff, the ADON assumed nothing had happened after asking Resident #1 if they felt safe and receiving a positive response. The Director of Nursing and the Administrator both stated that they would expect an allegation of sexual abuse to be reported to the state agency. However, due to the ADON's decision not to report the incident, the facility failed to comply with its policy to report all allegations of abuse immediately to the appropriate authorities.
Failure to Investigate Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged sexual abuse incident involving two residents. The incident occurred when a nurse aide entered a resident's room and found another resident standing beside the bed, zipping up their pants. Despite the aides' concerns and reports to the Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON), the facility did not conduct interviews with other residents or all staff present at the time of the incident. The facility's policy requires a comprehensive investigation of all abuse allegations, including obtaining personal statements from involved staff and residents, and ensuring the resident's safety and well-being. However, the LPN and ADON dismissed the aides' concerns as exaggerations and did not follow through with the necessary investigative steps. The ADON only asked one resident if they felt safe and assumed nothing had happened without further inquiry. The Director of Nursing and the Administrator were not aware of the incident's seriousness and did not ensure that the facility's abuse policy was followed. The lack of a proper investigation and failure to interview all relevant parties led to a deficiency in addressing the alleged abuse incident, leaving the residents' safety and well-being potentially compromised.
Failure to Secure Resident in Transport Van
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair within the facility van, leading to an accident. The resident, who had severely impaired cognition and required moderate assistance for transfers, was being transported from the hospital back to the facility. During the transport, the resident slid out of the wheelchair when the van turned into the facility's parking lot. The resident's wheelchair was not equipped with foot pedals, and the front wheels were not secured, which contributed to the incident. The resident was found lying on their left side in the van, with a skin abrasion on the left elbow and complaints of neck pain. The wheelchair's back wheels were secured, and the shoulder/lap belt was still in place, but the seatbelt was incorrectly positioned over the armrests instead of under them. The transporter, who had been trained by a previous staff member, did not secure the front wheels of the wheelchair, which was a critical oversight. The incident was reported by the transporter, and emergency services were called to assist the resident, who was then taken back to the hospital for evaluation. The hospital report indicated that the resident had no acute injuries but showed signs of degenerative spondylosis in the cervical spine. The facility did not have a policy in place for securing residents in the transport van, which contributed to the deficiency.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents' right to be free from sexual abuse. Staff observed the residents engaging in sexual activities without assessing their capacity to consent. Both residents had legal guardians and cognitive impairments, with one resident having a history of hypersexual behavior. Despite these factors, the facility did not complete the required assessments to determine their ability to consent to sexual activity before the incident occurred. Resident #1 had a history of wandering and incarceration related to sexual behaviors. The resident's quarterly Minimum Data Set (MDS) indicated severely impaired cognition. Staff documented multiple instances of Resident #1 wandering into other residents' rooms and being inappropriate with Resident #2. On the evening of 4/28/24, staff found Resident #1 and Resident #2 naked in bed together. The facility initiated 15-minute checks and completed a capacity to consent assessment only after the incident. Resident #2 had a history of hypersexual behavior and was under guardianship. The resident's medical records indicated periods of mania, disrobing, and delusional beliefs. Staff observed Resident #2 engaging in attention-seeking behaviors towards Resident #1, including holding hands and sitting close together. Despite these observations, no specific interventions were put in place until after the incident. The facility's failure to assess the residents' capacity to consent and implement appropriate interventions led to the deficiency.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents. The investigation did not include interviews with other residents to assess if they felt safe or had been subjected to or witnessed abuse. Additionally, not all staff present at the time of the alleged incident were interviewed. The facility's census was 89 at the time of the incident. Resident #1, who was admitted with diagnoses including unspecified dementia and vascular dementia, was assessed as having severely impaired cognition and had a history of inappropriate behavior. Resident #2, admitted with diagnoses including bipolar disorder and vascular dementia, had a history of hypersexual behavior and delusional beliefs. On the evening of the incident, both residents were found undressed in Resident #1's bed, engaging in consensual acts according to their statements. The Director of Nursing (DON) was aware of the escalating affectionate behavior between the two residents but did not implement specific interventions. After the incident, the DON interviewed the involved residents and one staff member but did not interview other residents or all staff present. The facility's abuse and neglect policy mandates immediate reporting and thorough investigation of all allegations, which was not fully adhered to in this case.
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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