Quail Run Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cameron, Missouri.
- Location
- 1405 West Grand Ave, Cameron, Missouri 64429
- CMS Provider Number
- 265353
- Inspections on file
- 16
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Quail Run Health Care Center during CMS and state inspections, most recent first.
A resident with schizophrenia, bipolar disorder, depression, anxiety, obesity, and a history of significant behavioral and psychiatric issues was admitted after a preadmission review deemed the individual appropriate for care, with a care plan noting anger, threats, suicidal thoughts, and need for 2-person assistance. Nursing notes described escalating anxiety, frequent requests for hospice, excessive call light use, attempts to pull staff into bed, and an episode involving chest pain, suicidal/homicidal statements, and object throwing that led to EMS transport to a hospital. After the hospital treated the resident and sought to return the individual, facility social services informed the hospital and the guardian that the resident would not be accepted back, and the Administrator cited behavioral concerns and need for psychiatry as reasons; however, the facility failed to document in the medical record any reason why the resident’s needs could not be met at the time of attempted return, contrary to its own transfer/discharge policy.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving three residents. One resident with cognitive impairment was not assisted during a meal, leading to unsanitary eating conditions. Another resident wore stained clothing and was not offered a change, while their meal was also compromised by flies. A third resident expressed dissatisfaction with being addressed by nicknames, which staff continued to use despite the resident's preferences.
The facility failed to ensure call lights were within reach for two residents with severe cognitive impairment. Observations showed call lights on the floor, inaccessible to the residents, despite staff entering and exiting their rooms. The DON confirmed the expectation for call lights to be within reach at all times.
The facility failed to address and communicate resident council concerns, as meeting minutes showed unresolved issues like laundry problems, cold food, and cleanliness. Ten residents were unaware of the grievance process, and interviews revealed a lack of follow-up on grievances, indicating a breakdown in communication and accountability.
The facility failed to invoke the Durable Power of Attorney for a resident with severe cognitive impairments before allowing them to sign an OHDNR form. Additionally, the facility did not document another resident's code status, despite their intact cognitive skills and multiple diagnoses. Staff interviews confirmed that these deficiencies were against facility policy, which mandates proper documentation and respect for residents' treatment preferences.
The facility failed to maintain a sanitary and comfortable environment, with observations of unclean floors, sticky bathroom surfaces, and persistent urine odors in several areas. Maintenance issues included missing call light cords, a difficult-to-open dining room door, and a lack of backflow preventers on shower hoses. Interviews revealed a lack of awareness and communication regarding necessary repairs and cleaning duties, with high staff turnover contributing to the problem.
The facility failed to ensure that ten out of eleven residents knew who the Grievance Official was and how to file a grievance. Despite having a grievance policy, the residents were not informed about their rights or the grievance process, as evidenced by the lack of discussion in resident council meeting minutes. Interviews with staff revealed that the Activity Director and Administrator did not effectively communicate this information to the residents.
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan only addressed a fall, lacking coverage for obesity, urinary incontinence, and diabetes. Another resident's care plan did not include their code status, and a third resident's care plan failed to address their dialysis needs. The facility also lacked a care plan policy.
The facility failed to update care plans quarterly for two residents, leading to deficiencies in care management. One resident's care plan lacked updates for verbal behaviors, while another resident was not invited to care plan meetings. Staff interviews revealed inconsistencies in inviting residents and maintaining documentation.
The facility failed to obtain a physician's order for a resident's dialysis and did not properly monitor low air loss mattress settings for two residents. One resident lacked a care plan addressing dialysis, while two others had mattresses set incorrectly, with no physician's orders or proper documentation. Staff interviews revealed inconsistencies in monitoring and knowledge of correct settings.
The facility failed to provide adequate perineal care and maintain personal hygiene for several residents, leading to deficiencies in care. Observations revealed improper cleaning practices and inconsistent shower schedules, affecting residents' well-being. A resident was found in a saturated incontinence brief with skin issues, indicating a lack of timely care.
The facility did not ensure that three CNAs completed required competencies upon hire and annually. The Administrator could not find competency records for these CNAs and acknowledged that competencies were not being completed as expected. Additionally, the facility lacked a policy for CNA competencies.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist, affecting three residents. A resident with severe cognitive impairment did not have documented reviews after an attempted dosage reduction. Another resident had no physician response to a pharmacist's recommendation on Haldol use. A third resident's care plan noted risks from psychotropic drugs, but physician notification of recommended dose reductions was lacking.
A LTC facility had a medication error rate of 26.67%, affecting three residents. Errors included improper blood sugar testing, use of expired insulin, incorrect administration of artificial tears, and improper mixing of Metamucil and Miralax. Additionally, Flonase nasal spray was administered incorrectly, with only one spray given instead of two.
The facility failed to maintain a sanitary kitchen environment, with observations of dirt, dust, and broken tiles, and lacked a policy for food storage and sanitation. Improper food handling was noted, with raw chicken left in water without running water and dirty dishes on the clean rack. Staff interviews revealed unmet expectations for cleanliness and repair.
The facility failed to maintain an effective pest control program, leading to a fly infestation affecting all 56 residents. Flies were observed landing on residents and their food in rooms and dining areas. Despite starting a new pest control program, the facility did not provide a pest control policy, and flies were entering through a door gap. The Maintenance Director and Administrator acknowledged the issue and were working with an outside service to address it.
A significant medication error occurred when an LPN administered expired Insulin Lispro to a resident with diabetes mellitus. The insulin was used despite being past its expiration date, as confirmed by the DON. The facility lacked a policy for insulin administration, contributing to the error.
The facility failed to ensure the Dietary Manager had the necessary skills and competencies to manage food and nutrition services. The DM, hired without prior food service training or certification, only had a Food Handler Certificate and lacked managerial experience. Despite working as a dietary aide, the DM had not completed the required dietary manager's course. Interviews with the DM, RD, and Administrator indicated that training was pending, and there was an expectation for the DM to be knowledgeable about kitchen regulations.
Facility staff failed to follow hand hygiene protocols while providing care to a resident with severe cognitive impairment and incontinence. Staff members entered the resident's room, donned gloves, and performed personal care tasks without washing their hands, despite facility policies requiring hand hygiene before and after resident contact and glove changes.
Failure to Document Justification for Refusing Resident Readmission After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return from the hospital without a documented reason in the medical record explaining why the resident’s needs could not be met. Facility policy stated that when a resident is sent to an acute care setting, it is considered a transfer with an expected return, and that if the facility does not permit a resident’s return based on inability to meet needs, the facility must notify the resident/representative in writing and document the reason in the record. The policy also required that discharge decisions after an emergency transfer be based on the resident’s status at the time of attempted return, and that nursing notes include documentation of appropriate orientation and preparation prior to transfer or discharge. The resident involved had a PASRR dated several years prior showing manic and depressive episodes, serious functional problems, a history of intense psychiatric treatment, frequent crisis hotline calls with threats of self-harm, difficulty getting along with others, and a need for redirection. The preadmission packet and care plan identified diagnoses of anxiety, diabetes, schizophrenia, bipolar disorder, depression, obesity, and behaviors including becoming angry quickly, making threats, suicidal thoughts without a specific plan, risk for aggression, anxiety, irritability, difficulty getting along with others, and a need for two staff for care due to size and behaviors. The facility’s DON reviewed the preadmission packet and deemed the resident appropriate for admission, and the resident was admitted with the Public Administrator as guardian. Nursing notes documented that after admission the resident was very anxious, repeatedly approached the nurses’ station, requested hospice be called, used the call light frequently for minor issues, attempted to pull staff into bed, and required care in pairs. On the day of transfer, the resident returned from a smoke break, again requested hospice, reported having a mental and physical crisis, complained of chest pain radiating down the left arm, and stated an intention to harm self and everyone around. EMS was called, the resident began throwing things, EMS de-escalated the situation, and the resident was transferred to a hospital. Subsequently, the hospital social worker and the Public Administrator reported that facility social services stated the resident would not be accepted back and delivered a letter declining readmission, while the Administrator stated the facility would not allow return because the resident needed psychiatric evaluation and she felt other residents would not be safe. There was no documented reason in the resident’s medical record at the facility explaining why the resident’s needs could not be met upon attempted return, despite the facility’s decision not to readmit the resident.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving three residents. One resident, who had severe cognitive impairment and required assistance with daily activities, was not properly assisted during a meal. The resident was seated too far from the dining table, resulting in food falling onto the table and their lap. Despite the presence of staff, the resident was left to eat food directly off the table, which was also being landed on by flies, without any assistance or intervention from the staff. Another resident, also with severe cognitive impairment, was observed wearing stained clothing and was not offered a change of clothes by the staff. This resident's meal was also affected by flies, yet the staff did not provide a new plate of food. The resident attempted to address the fly issue themselves by retrieving a fly swatter, but no staff intervention was noted to ensure the resident's meal was sanitary or to address their soiled clothing. A third resident, who had intact cognitive skills, expressed dissatisfaction with being addressed by nicknames such as "honey" or "sweetie," which they found disrespectful. Despite the resident's preference to be called by their given name or formal titles, staff continued to use these nicknames. Interviews with staff revealed a lack of awareness and adherence to the resident's preferences, indicating a failure to respect the resident's right to self-determination and dignity.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach while they were in their rooms. Resident #46, who had severe cognitive impairment and required assistance for mobility and personal care, was observed multiple times with the call light lying on the floor behind the bed, out of reach. Despite the resident's inability to reach the call light, staff members, including a CNA, entered and exited the room without providing the call light to the resident. Similarly, Resident #39, also with severe cognitive impairment and dependent on staff for personal care, was observed with the call light cord draped across the bed frame and the call light resting on the floor. Staff members assisted the resident with care but failed to ensure the call light was accessible. Interviews with staff, including the Director of Nurses, confirmed the expectation that call lights should be within reach at all times, which was not adhered to in these instances.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and communicate the concerns and recommendations of the resident council, as evidenced by the lack of follow-up on issues raised during council meetings. The resident council meeting minutes from August, October, and November indicated recurring issues such as laundry problems, call light response times, trash accumulation, missing clothes, cold food, and cleanliness concerns. However, the meeting forms did not document how these issues were resolved, who was responsible for addressing them, or whether the resolutions were satisfactory to the residents. This lack of documentation and follow-up suggests a failure in the facility's grievance process. Additionally, during a group interview, ten out of eleven residents reported being unaware of the grievance official and the process for filing grievances. They also expressed that they did not receive follow-up from the staff regarding their concerns. Interviews with the Activity Director and the Administrator revealed that while resident concerns were discussed in meetings, there was an expectation that grievances should be followed up on, which was not happening. This indicates a breakdown in communication and accountability within the facility's grievance handling process.
Failure to Properly Invoke DPOA and Document Code Status
Penalty
Summary
The facility failed to ensure that staff properly invoked the Durable Power of Attorney (DPOA) for a resident before allowing them to sign an Outside of Hospital Do Not Resuscitate (OHDNR) form. This affected one resident who had severe cognitive impairments, including dementia and traumatic brain injury, and was dependent on staff for daily activities. Despite these impairments, the resident was allowed to sign the OHDNR form without the activation of the DPOA, which should have been done given the resident's incapacity to make informed decisions. Additionally, the facility did not obtain advance directives for another resident's code status, which is crucial for determining whether the resident wished to have cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest. This resident had intact cognitive skills and multiple diagnoses, including cancer and congestive heart failure, but their care plan, physician order sheet, and face sheet did not address their code status. Interviews with staff, including the MDS/Care Plan Coordinator and the Director of Nursing, confirmed that the resident's code status should have been documented and care planned. The report highlights a lack of adherence to the facility's policy on advance directives, which mandates that residents' treatment preferences be documented and respected. Interviews with various staff members, including the Social Services Designee and the Administrator, revealed a lack of clarity and action regarding the residents' decision-making capacities and the necessary steps to ensure their rights and preferences were upheld. This oversight resulted in a failure to properly document and respect the residents' advance directives and code status preferences.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas. Observations revealed dirt and debris on floors, sticky bathroom floors, and brown debris in toilet bowls in several rooms. Additionally, the shower room on the South Hall had broken floor tiles, a cracked light cover, and broken window blinds. The facility also had issues with call light cords being missing or too short in several bathrooms, and a dining room door that was difficult for residents to open. Furthermore, the South Hall and several rooms consistently smelled of urine over multiple days. Interviews with the Maintenance Supervisor and Housekeeping Supervisor highlighted a lack of awareness and communication regarding necessary repairs and cleaning duties. The Maintenance Supervisor was unaware of the need for backflow preventers on shower hoses and did not have work orders for missing call light cords. The Housekeeping Supervisor acknowledged high staff turnover and the need to get back on track with cleaning duties. The Administrator expressed expectations for a clean and odor-free facility in good repair, but these standards were not met, as evidenced by the observations and interviews.
Residents Unaware of Grievance Process
Penalty
Summary
The facility failed to ensure that ten out of eleven sampled residents who participated in a group meeting were aware of who the Grievance Official was and how to file a grievance. The facility's grievance policy, which was undated, outlined that residents have the right to voice grievances without fear of discrimination or reprisal and that the facility must make prompt efforts to resolve these grievances. However, during a group meeting, it was found that the majority of the residents did not know the identity of the Grievance Official or the process for filing a grievance. This lack of awareness was also reflected in the resident council meeting minutes, which did not indicate whether resident rights or grievance procedures were reviewed or discussed. Interviews conducted with facility staff revealed gaps in communication and education regarding the grievance process. The Activity Director, who had been in the position since September, was responsible for setting up resident council meetings but did not ensure that residents were informed about their rights or the grievance process. The Administrator acknowledged that residents should be aware of the Grievance Official and the procedure for filing grievances. Additionally, the Regional Quality Assurance Nurse mentioned addressing grievances with residents back in April, but this information did not seem to have been effectively communicated or retained by the residents.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #25, who had minimal cognitive deficit and required assistance for hygiene and transfers, only had a care plan addressing a fall, lacking a comprehensive plan for other needs such as obesity, urinary incontinence, and diabetes. Resident #18, with intact cognitive skills and multiple diagnoses including cancer and COPD, did not have their code status addressed in the care plan, physician order sheet, or face sheet, which was acknowledged as necessary by the MDS/Care Plan Coordinator and the Director of Nursing. Resident #49, who had severely impaired cognitive skills and required dialysis, did not have this critical aspect of their care included in their care plan. The MDS/Care Plan Coordinator and the Director of Nursing both confirmed that the care plan should have addressed the resident's dialysis needs. The facility also lacked a care plan policy, which contributed to these deficiencies, as evidenced by the absence of comprehensive care plans for the sampled residents.
Failure to Update Care Plans Quarterly
Penalty
Summary
The facility failed to review and update care plans quarterly for two residents, leading to deficiencies in their care management. Resident #36's care plan was not updated since May 2024, and it did not address verbal behaviors identified in the most recent MDS assessment. This resident had a mild cognitive deficit, Alzheimer's disease, urinary incontinence, and required assistance with daily activities. The lack of updates in the care plan indicates a failure to incorporate current assessments into the resident's care strategy. Resident #43's care plan conference summary from May 2024 was the only documentation available, and it did not indicate whether the resident was invited or attended the meeting. The resident, who had intact cognitive skills, upper extremity impairment, and was frequently incontinent, reported not being invited to any care plan meetings. Interviews with facility staff revealed inconsistencies in inviting residents and responsible parties to care plan meetings and maintaining documentation of these meetings. The Director of Nursing confirmed that care plans should be updated quarterly and as needed, but this was not adhered to in these cases.
Deficiencies in Dialysis Orders and Mattress Settings
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality care, as evidenced by the lack of a physician's order for a resident to attend dialysis. This deficiency affected one resident who had severe cognitive impairment and multiple diagnoses, including stroke, COPD, and diabetes mellitus. The resident's care plan did not address the need for dialysis, and there was no physician's order documented in the resident's records. Interviews with facility staff, including the MDS/Care Plan Coordinator, LPN, and DON, confirmed that the care plan should have included dialysis and that a physician's order was necessary. Additionally, the facility did not properly monitor the settings of low air loss mattresses for two residents. One resident, with moderately impaired cognitive skills and a history of pressure ulcers, had a mattress set incorrectly at 300 pounds, despite weighing significantly less. The resident's care plan did not include a physician's order for the mattress or its settings. Observations showed that the mattress settings were not adjusted according to the resident's weight, and staff interviews revealed a lack of documentation and knowledge regarding the correct settings. The second resident, with severe cognitive impairment and multiple diagnoses, also had a low air loss mattress set incorrectly at 230 pounds, despite weighing more. Similar to the first case, there was no physician's order for the mattress or its settings in the resident's care plan. Interviews with nursing staff indicated that while they were responsible for monitoring the mattress settings, there was no consistent documentation or understanding of the correct settings. The Regional QA nurse confirmed that a physician's order should guide the mattress settings based on the manufacturer's guidelines.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide adequate perineal care and maintain personal hygiene for several residents, leading to deficiencies in care. Observations revealed that staff did not clean all areas of the skin where urine or feces had touched, and they used the same area of a wipe to clean different areas, which is against proper hygiene practices. For instance, Resident #21, who was always incontinent of bowel and bladder and dependent on staff for personal hygiene, did not receive complete perineal care. Staff members were observed not separating and cleaning all areas of the skin, and they did not wash their hands between glove changes. Additionally, the facility did not ensure that residents received showers or bed baths as per their preferences and care plans. Resident #43, who required assistance due to hemiplegia, reported not receiving showers on scheduled days, which affected their sense of cleanliness and well-being. The facility lacked a dedicated shower aide, and the shower schedule was inconsistently followed, leading to some residents not receiving their showers as planned. This inconsistency was further exacerbated by a change in the facility's computer program, which disrupted the documentation of shower schedules. Resident #25, who required assistance for hygiene and was bound to a wheelchair, was found in a saturated incontinence brief with a strong odor of urine, indicating a lack of timely care. The resident's skin was dark red and had an open slit, suggesting prolonged exposure to moisture and inadequate care. Staff interviews confirmed that the resident had not been checked or cleaned since early morning, despite the expectation of providing incontinent care every two to three hours. The facility's failure to address these care needs highlights significant deficiencies in maintaining residents' personal hygiene and dignity.
Failure to Complete CNA Competencies
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) completed required competencies upon hire and annually. The staff roster indicated that CNA E was hired on February 21, 2024, CNA D on August 21, 2023, and CNA C on April 15, 2024. During an interview, the Administrator admitted that she could not locate the competency records for these CNAs and acknowledged that competencies were not being completed as expected. The facility did not have a policy in place for CNA competencies, contributing to this oversight.
Failure in Monthly Drug Regimen Review and Physician Notification
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a comprehensive monthly drug regimen review for each resident, which included assessing for unnecessary medications, psychoactive medication management, and drug irregularities. This deficiency affected three residents, who did not receive appropriate medication reviews or physician notifications regarding the pharmacist's recommendations. For instance, Resident #4's records showed an attempted gradual dosage reduction for Trazodone and Zoloft, but no further drug regimen reviews were documented. The resident had severe cognitive impairment and was dependent on staff for daily activities, receiving multiple psychotropic medications for conditions such as depression and dementia. Similarly, Resident #51's records indicated that the pharmacist recommended a 14-day limit on Haldol prescriptions, but there was no documented response from the physician. This resident was at risk for side effects from antidepressant and antipsychotic use. Resident #1's care plan highlighted the risk of side effects from psychotropic drugs, yet there was no evidence that the physician was notified of the pharmacist's recommendations for gradual dose reductions of several medications. The Regional Quality Assurance Nurse confirmed that drug regimen reviews should be completed monthly and that the previous Director of Nursing did not consistently fulfill this requirement.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 26.67% with eight errors out of 30 opportunities. This affected three residents, including one who had their blood sugar checked improperly and was administered expired insulin. The Licensed Practical Nurse (LPN) involved did not allow the alcohol to dry completely before pricking the resident's finger and used insulin that was past its expiration date. Another resident received incorrect administration of artificial tears and a mixture of Metamucil and Miralax. The Certified Medication Technician (CMT) touched the resident's eyelid and eyelashes with the eye dropper and did not apply lacrimal pressure for the recommended duration. Additionally, the CMT mixed Metamucil and Miralax in the same cup with insufficient water, contrary to the instructions on the labels. A third resident was administered Flonase nasal spray incorrectly. The CMT did not shake the bottle, have the resident blow their nose, or close one nostril before administering the spray. Only one spray was given instead of the prescribed two. The CMT also improperly administered artificial tears by touching the resident's eyelid and eyelashes with the dropper and not applying lacrimal pressure for the recommended time.
Unsanitary Kitchen Conditions and Improper Food Handling
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, which had the potential to affect all residents. Observations revealed several unsanitary conditions, including a light switch covered in dirt, a vent above the hand washing sink covered in dust and debris, and food particles on the back-splash behind the stove. Additionally, the light in the dish-room was cracked, multiple tiles on the kitchen and dish room floors were broken, and there was a black substance on the wall behind the three-compartment sink. The facility did not have a policy addressing food storage, kitchen cleaning, and sanitation. Further observations and interviews highlighted improper food handling practices. Raw chicken quarters were found sitting in water in the middle compartment of the three-compartment sink without running water, a method instructed by the Dietary Manager. The chicken had been in the sink for an hour. Additionally, a pan from the clean dish rack was found with food debris, indicating it was not properly cleaned. Interviews with the Registered Dietitian and Maintenance Supervisor revealed expectations for cleanliness and repair were not met, and there was a lack of awareness regarding the necessary repairs and cleaning schedules.
Facility Fails to Control Fly Infestation Affecting Residents
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies within the premises, potentially affecting all 56 residents. Observations on multiple occasions revealed flies landing on residents and their belongings, particularly in their rooms and the dining area. During meal times, flies were seen landing on residents' food, and residents were observed swatting at the flies with their hands. Despite the presence of flies, residents consumed the food that the flies had landed on, indicating a lack of effective pest control measures. Interviews with the Maintenance Director and the Administrator highlighted that the facility had recently initiated a new pest control program. However, the Maintenance Director acknowledged that flies were entering the facility through a door gap by the gazebo exit door. Both the Maintenance Director and the Administrator agreed that residents should not have flies in their rooms or dining areas, nor should flies land on their food. The facility was in the process of working with an outside pest control service to develop a fly control program, but at the time of the survey, the facility did not provide a pest control policy when requested.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving the use of expired insulin. Specifically, a Licensed Practical Nurse (LPN) administered four units of expired Insulin Lispro to Resident #48, who had a physician's order for insulin administration based on a sliding scale for diabetes mellitus. The insulin vial used was opened and expired, yet it was still administered to the resident. During an interview, the Director of Nursing (DON) confirmed that staff should check insulin vials for expiration dates and should not use them if expired. The facility did not provide a policy for the administration of insulin, contributing to this oversight.
Inadequate Competency of Dietary Manager
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to effectively manage the food and nutrition services. The DM was hired on March 1, 2024, as a Food Service Manager but lacked prior food service training and did not hold any certification in food service management or as a dietary manager. The DM only possessed a Food Handler Certificate obtained on November 5, 2024, from Always Safe Food Company. Despite having worked as a dietary aide, the DM had no managerial experience and had not completed the required dietary manager's course. Interviews with the DM, Registered Dietitian (RD), and the Administrator revealed that the facility was in the process of initiating the DM's training, but it had not yet been completed. The RD and Administrator both expressed expectations that the DM should have completed the necessary training to manage the kitchen and be knowledgeable about all relevant regulations.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility staff failed to adhere to hand hygiene protocols during the care of a resident with severe cognitive impairment and multiple diagnoses, including stroke, heart disease, and schizophrenia. The resident was dependent on staff for personal hygiene and was incontinent of bowel and bladder. During an observation, two staff members, NA A and CNA D, entered the resident's room without performing hand hygiene. They proceeded to put on gloves without washing their hands and engaged in personal care tasks, including washing the resident's face and performing perineal care, without adhering to proper hand hygiene practices. NA A removed gloves and left the resident's room without performing hand hygiene, then returned with clean linens, again failing to wash hands before resuming care. Interviews with RN A and the Director of Nursing revealed that staff were expected to perform hand hygiene upon entering and exiting resident rooms, before and between glove changes, and when hands were visibly soiled. The failure to follow these protocols was observed during the care of the resident, indicating a deficiency in the facility's infection prevention and control program.
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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