Rehabilitation Center Of Independence, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Missouri.
- Location
- 1800 S Swope Drive, Independence, Missouri 64057
- CMS Provider Number
- 265693
- Inspections on file
- 33
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rehabilitation Center Of Independence, The during CMS and state inspections, most recent first.
A resident with COPD, CHF, CKD stage 3, MDD, and anxiety, who was moderately cognitively impaired but able to communicate, discovered that money was missing from their bank account after receiving a lump-sum SSA back payment. While reviewing the account with a SW and a therapist, a $350 charge to a wireless carrier bearing the SSD’s name was identified, matching a prior text in which the SSD had asked the therapist to borrow $350 for a phone bill. The resident reported never authorizing the SSD to use their debit card, and bank records showed this payment along with multiple ATM withdrawals totaling several thousand dollars. The SSD denied using the resident’s card or receiving money, but the documented transaction, text messages, and interviews showed that the SSD used the resident’s funds to pay a personal cell phone bill, in violation of the facility’s abuse and misappropriation policy.
A resident with a history of falls and traumatic brain injury experienced a fall resulting in multiple injuries, including facial bruising, a laceration, and broken teeth. Staff notified the physician only about knee pain and did not report the facial injuries or broken teeth, nor did they fully document the extent of injuries or interventions provided. The physician and nurse practitioner were unaware of the full scope of injuries, and facility leadership confirmed that required notifications and documentation were not completed.
A facility failed to manage a diabetic resident's care, leading to hospitalization. The resident's insulin orders were not transcribed, and blood glucose monitoring was inadequate, resulting in hyperglycemia with a blood sugar level of 541 mg/dL. The resident exhibited signs of hyperglycemia, such as excessive hunger and anger, which were not recognized by staff. Interviews revealed a lack of awareness and inadequate processes for ensuring accurate transcription of physician's orders.
The facility failed to maintain adequate nursing staffing levels, as established by their own standards, resulting in a deficiency in providing appropriate care and services to residents. The facility's minimum staffing expectation was 2.8 nursing staff hours per patient per day (PPD), but this was not consistently met, with the lowest recorded at 2.03 PPD. The Administrator and DON acknowledged the routine failure to meet the staffing benchmark, potentially affecting all residents.
The facility failed to provide palatable foods at appropriate temperatures, affecting residents across multiple units. Residents reported meals being cold and served late, often due to staffing shortages. Despite ongoing complaints documented in Resident Council Meeting Minutes, issues persisted, with a test tray evaluation confirming improper food temperatures. The Food Service Supervisor and Administrator acknowledged the concerns.
The facility was unable to provide documentation of regular QAPI meetings and evidence of participation by required parties. The Administrator reported plans for monthly meetings but could not locate all attendance records since the last survey. Records were available for meetings in June, August, September, and October 2024, but no additional evidence of required meetings or attendance documentation was found, affecting all residents.
The facility failed to ensure dignified care for three residents. A resident with intact cognition was not provided with necessary adaptive feeding equipment, leading to frustration. Another resident was left without a bed, resulting in discomfort and inadequate rest. Additionally, a resident experienced a breach of dignity during perineal care when a staff member used profane language in their presence.
The facility failed to address ongoing grievances from residents regarding showers, laundry, and food shortages. Despite repeated reports in Resident Council meetings, issues such as missing laundry items, inadequate food supplies, and unclean rooms persisted. Interviews with the Administrator and DON indicated that while concerns were discussed in meetings, no actions were taken to resolve them.
The facility failed to provide adequate care for activities of daily living, including showers and toileting assistance, due to staffing shortages. Residents reported receiving fewer showers than scheduled, and one resident was left unattended on the toilet for over 20 minutes despite activating the call light. Staff interviews confirmed these issues, and there was no documentation of residents refusing care. The facility's policies on shower frequency and call light response were not followed, affecting the quality of care for multiple residents.
The facility did not employ a qualified social worker as required for facilities with more than 120 beds, impacting all 96 residents. The social worker held a Bachelor of Arts in Human Services but was not licensed by the state and lacked the required year of supervised experience. The social worker confirmed these deficiencies during an interview.
The facility failed to ensure proper infection control during wound care for two residents, as the LVN did not perform hand hygiene before donning gloves and touched surfaces before starting care. Additionally, Enhanced Barrier Precautions were not implemented for a resident with a pressure injury and catheter, as required by the care plan. Observations showed no signage or PPE available, and the DON acknowledged the oversight.
A resident's room was changed without prior notice while they were out for an appointment, leading to a misunderstanding with their former roommate. The facility's policy requires advance notice for room changes, but this was not followed, as confirmed by the social worker and acknowledged by the administrator.
A resident, who required a Hoyer lift for transfers, reported falling during a transfer by a Restorative Nursing Aide and Maintenance Supervisor. The staff did not notify the nurse or physician, and the incident was not documented in progress notes. The resident, with a history of brain injury and repeated falls, was later found with unreported abrasions on the left knee.
The facility did not provide appropriate notification of pending Medicare benefit changes for a resident. A review revealed that there was no documentation available for the required Beneficiary Notice for a resident discharged within the last six months. The Social Worker, new to the position, could not provide proof of notification letters sent to the resident.
A resident with a history of metabolic encephalopathy and CVA was transferred to a hospital due to a change in condition without the required written notice being sent to the resident or their representative. Facility staff, including an LPN and the DON, confirmed the oversight, which was against the facility's policy.
A resident was transferred to a hospital without receiving a written notice of the facility's bed-hold policy, as required by the facility's transfer and discharge policy. The resident, with a history of metabolic encephalopathy and hemiparesis, was transferred due to a change in medical condition. Interviews with staff confirmed the oversight, as the notice was not provided to the resident or their representative.
A facility failed to accurately document a resident's skin condition, compromising care. The resident, with a history of brain injury and falls, sustained abrasions during a transfer on admission day, which were not documented by the LVN. The resident reported falling, but staff stated the resident slipped without falling. The RNA involved was suspended and unavailable for comment.
A facility failed to timely obtain a physician-ordered urinalysis (UA) sample for a resident with multiple health conditions, including cellulitis and diabetes. The UA order was dated over a year before the sample was collected, with no explanation for the delay provided by the DON.
The facility failed to provide meaningful weekend activities for two residents and did not assist a resident in attending desired activities. A resident with intact cognitive status was not helped out of bed to attend bingo, while two other residents reported a lack of weekend activities, leading to boredom. Activity records confirmed limited participation in weekend activities, and the Activity Director acknowledged the absence of staff supervision on weekends.
The facility failed to supervise two residents while smoking, as required by its policy, leading them to smoke unsupervised in non-designated areas. Despite the policy mandating supervision and designated smoking areas, observations showed residents smoking near the front door without staff present. Interviews revealed that staff shortages and inaccessible designated areas contributed to this deficiency.
A resident with multiple diagnoses, including overactive bladder and chronic pain syndrome, did not receive proper perineal care as per facility policy. An RNA failed to adequately spread the resident's knees for cleaning, citing the resident's contracted state, while a CNA disagreed with the RNA's method. The resident, cognitively intact and dependent on staff for toileting, expressed dissatisfaction with the care, stating it was not done correctly.
A resident with dementia and a gastrostomy tube was not given prescribed supplemental feeding despite low meal intake. Observations and records showed the resident ate less than 50% of meals on several occasions, yet staff failed to administer Glucerna 1.5 as ordered. The DON confirmed that staff were expected to monitor intake and provide supplemental feeding as needed.
The facility did not follow the prescribed pureed diet menu for two residents, as observed during a meal service. The menu included pureed BBQ meatballs, mashed potatoes with gravy, pureed buttered peas, pureed brownie, and pureed buttered white bread. However, the bread was not pureed and served to the residents, which was acknowledged by the Food Services Manager.
Misappropriation of Resident Funds by Social Services Director
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when the Social Services Director (SSD) used the resident’s debit card to pay the SSD’s personal cell phone bill in the amount of $350.00. The facility’s Abuse Prevention and Prohibition Program stated that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property, and that the facility is committed to protecting residents from abuse by anyone, including staff. Despite this policy, the SSD’s name appeared on a $350.00 wireless cell phone carrier transaction drawn from the resident’s bank account, and the resident later reported missing money and denied authorizing the SSD to use the debit card for this purpose. The resident involved had multiple medical and psychosocial conditions, including COPD, chronic systolic (congestive) heart failure, chronic kidney disease stage 3, major depressive disorder (recurrent, moderate), and anxiety. A quarterly MDS showed the resident was moderately cognitively impaired but able to understand others and be understood. The resident’s care plan documented psychosocial well-being problems related to depression, anxiety, cognitive communication deficit, chronic pain, and respiratory insufficiency, and noted that the resident discovered missing money, which prompted an investigation and involvement of the police. Following discovery of the missing funds, the resident displayed increased tearfulness and reported never giving the SSD permission to use the debit card to pay a cell phone bill. Interviews and record reviews showed a sequence of events linking the SSD to the misappropriation. Therapist A reported receiving a text message from the SSD asking to borrow $350.00 to pay a cell phone bill; Therapist A declined. Later, while assisting the resident and Social Worker (SW) A in reviewing the resident’s bank account, Therapist A observed a $350.00 charge to a wireless carrier with the SSD’s name on it and took a picture of the transaction before reporting it to the Administrator. SW A stated that the resident came to the office upset that all of the resident’s money was gone, and that review of the account revealed the SSD’s cell phone bill payment. The resident had recently received a lump-sum Social Security back payment, paid the facility balance, and had about $9,000 remaining, with only about $1,000 left when the concern was raised. The Administrator reported that a total of $8,000 was missing from the resident’s account with multiple ATM withdrawals, that $350.00 was verified as taken by the SSD to pay a cell phone bill, and that law enforcement and the bank were investigating. Although the SSD denied using the resident’s debit card or receiving money or gifts from the resident, the bank record, the therapist’s text messages, and the resident’s statements collectively supported that the SSD used the resident’s funds without authorization, constituting misappropriation of property.
Failure to Notify Physician of All Resident Injuries After Fall
Penalty
Summary
The facility failed to ensure that a resident's physician was notified of all injuries sustained after a fall, as required by facility policy. The resident, who had a history of muscle weakness, repeated falls, and a traumatic subdural hemorrhage, experienced a fall resulting in multiple injuries, including a bruise to the right knee, facial bruising, swelling, a laceration to the top lip, and broken implanted teeth. While the fall was reported and an x-ray was ordered for the knee, there was no documentation that the physician was informed of the facial injuries or the broken teeth. The resident reported pain in the knee, hand, chin, and mouth, and described significant facial swelling and bruising, but these complaints and injuries were not fully communicated to the physician or addressed in the medical record. Interviews with staff revealed that the LPN who responded to the fall focused primarily on the resident's knee pain and did not recall informing the provider about the facial injuries or broken teeth. Other nursing staff assumed that all necessary notifications had been made and did not contact the physician regarding the additional injuries. Documentation in the progress notes and medical record was incomplete, with missing details about the location of pain, the extent of facial injuries, and the interventions provided, such as the application of steri-strips and ice packs. The physician and nurse practitioner both stated that they were not made aware of the full extent of the resident's injuries following the fall. Facility leadership, including the DON and Administrator, confirmed that their expectations were for all injuries and relevant facts to be reported to the physician and documented in the medical record. However, the investigation found that the required notifications and documentation did not occur, particularly regarding the resident's facial injuries and broken teeth. The lack of comprehensive assessment, notification, and documentation following the fall constituted a failure to follow facility policy and ensure appropriate medical oversight for the resident's injuries.
Failure to Manage Diabetic Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate care for a diabetic resident, leading to a significant health deficiency. Upon admission, the resident had a medical history of metabolic encephalopathy and diabetes, with specific orders for insulin administration and blood glucose monitoring. However, the facility staff did not transcribe or verify these orders, resulting in the omission of critical insulin doses and inadequate blood glucose monitoring. This oversight led to the resident experiencing hyperglycemia, with blood sugar levels reaching 541 mg/dL, and subsequent hospitalization. The resident exhibited signs of hyperglycemia, such as excessive hunger, anger, and frequent urination, which were not recognized or addressed by the facility staff. Despite the resident's disruptive behaviors and physical aggression, the staff did not assess or manage the resident's blood sugar levels appropriately. The facility's failure to implement the necessary care and services, as ordered by the medical provider, contributed to the resident's deteriorating condition and eventual transfer to a hospital. Interviews with the Administrator and the DON revealed a lack of awareness regarding the resident's unmonitored blood glucose levels and the unfulfilled insulin orders. The DON acknowledged the symptoms indicative of uncontrolled hyperglycemia but did not recognize them at the time of the resident's transfer. The facility's process for ensuring accurate transcription of physician's orders was inadequate, as evidenced by the missing checklist for the resident's admission. This deficiency highlights a critical lapse in the facility's care for diabetic residents, resulting in adverse outcomes for the resident involved.
Inadequate Nursing Staffing Levels
Penalty
Summary
The facility leadership failed to maintain adequate nursing staffing levels as established by their own standards, which resulted in a deficiency in providing appropriate nursing care and services to meet the needs of residents. The facility had set a minimum nurse staffing expectation of 2.8 nursing staff hours per patient per day (PPD), but a review of the facility's daily staffing hours for December 2024 revealed that this benchmark was not consistently met. On multiple days, the actual nursing staff hours worked were below the established minimum, with the lowest recorded at 2.03 PPD. During an interview with the Administrator and Director of Nursing (DON), it was acknowledged that the facility was routinely failing to meet the staffing benchmark. This deficiency had the potential to affect all residents living in the facility, as the inadequate staffing levels could compromise the quality of care and services provided to them. The report does not mention any specific residents or their conditions, focusing instead on the overall staffing inadequacies and the facility's failure to adhere to its own staffing standards.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to provide palatable foods per resident preferences for taste and temperature, as evidenced by improper food temperatures and delayed meal services. Multiple residents across four out of five units expressed concerns about the quality of food, specifically noting that meals were often cold and served later than the posted times. These issues were attributed to staffing shortages, which resulted in food trays sitting in hallways for extended periods before being served. Residents reported dissatisfaction with the taste and temperature of the food, with some opting to skip meals or order food from outside the facility. Resident interviews revealed consistent complaints about the food service, with residents describing meals as cold, unappetizing, and not served at the scheduled times. The Resident Council Meeting Minutes from the past five months documented ongoing issues with meal delays, lack of condiments, and unmet food preferences. Despite these documented complaints, the issues persisted, with residents continuing to express dissatisfaction with the food service during a recent Resident Council meeting. An observation of a breakfast meal service confirmed the residents' complaints, as a test tray evaluation showed that food temperatures were below acceptable levels. The Food Service Supervisor acknowledged that the food was too cold and had been left in the hallway for too long. The facility administrator also recognized the food complaints as a concern, indicating awareness of the deficiency but no immediate corrective actions were noted in the report.
Lack of Documentation for QAPI Meetings
Penalty
Summary
The facility was found deficient due to its inability to provide documentation of regular Quality Assurance Performance Improvement Plan (QAPI) meetings and evidence of participation by the required parties. During an interview, the Administrator stated that the committee planned to meet monthly but could not locate all verification of attendance for the QAPI meetings held since the last survey in June 2023. The Administrator provided records for meetings held in June, August, September, and October 2024, but there was no additional evidence of required meetings or documentation regarding those in attendance. This deficiency affected all facility residents.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure a dignified existence for three residents, as observed during a survey. Resident #39, who had intact cognition and required setup or clean-up assistance for eating, was not provided with the necessary adaptive feeding equipment. Despite having an occupational therapy order for a built-up utensil, the resident was left without assistance, leading to frustration and a feeling of disrespect when staff were unavailable to help with meals. Resident #66, who had intact cognition and was typically independent with toileting, was found to be sleeping in a manual wheelchair due to the absence of a bed in the room. The resident reported difficulty with the provided rocking recliner and expressed a preference for a bed, which was not accommodated by the facility. The resident's care plan did not address the need for assistance with transferring from the recliner, leading to discomfort and inadequate rest. Resident #82, who was cognitively intact and dependent on staff for toileting hygiene, experienced a breach of dignity during perineal care. A Restorative Nursing Aide used profane language directed at another staff member in the resident's presence, compromising the resident's right to a respectful environment. This incident was reported to the facility's administration, highlighting a failure to maintain a dignified and respectful atmosphere during care interactions.
Facility Fails to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during multiple Resident Council meetings. Over several months, residents consistently reported issues such as not receiving showers, missing laundry items, and inadequate food supplies. Specific concerns included the dietary department running out of milk, yogurt, and condiments, as well as meal trays not matching dining tickets due to food shortages. Additionally, residents reported that their rooms were not being cleaned daily, and they were not receiving their clothing back from the laundry department in a timely manner. Despite these ongoing complaints, there was no evidence in the meeting minutes that facility leadership had addressed the residents' concerns. During an observation of a Resident Council meeting, residents continued to report issues with lost or damaged laundry, shortages of paper towels and hand soap, and rooms not being cleaned daily. Interviews with the Administrator and the DON revealed that while the concerns were discussed in leadership and Interdisciplinary Team meetings, no concrete responses or actions were provided to address the issues raised by the residents.
Deficiencies in ADL Care and Response to Call Lights
Penalty
Summary
The facility failed to provide necessary nursing care and services for activities of daily living to several residents, as observed in multiple instances. Resident #2, who has cerebral palsy and requires substantial assistance for showers and transfers, reported receiving fewer showers than scheduled due to staff shortages. The resident's care plan indicated a need for two showers per week, but records showed inconsistencies in meeting this requirement. Interviews with staff confirmed that short staffing often led to rescheduling or skipping showers, and there was no documentation of the resident refusing showers. Resident #58, with diagnoses including seizure and chronic obstructive pulmonary disease, also experienced a reduction in scheduled showers due to understaffing. Despite the care plan specifying two showers per week, the resident reported receiving only one per week and expressed frustration over the lack of assistance, particularly on weekends. The facility's policy required residents to sign a form if they refused showers, but there was no record of such refusals for Resident #58. Additionally, Resident #70, who is dependent on staff for toileting assistance, was left unattended on the toilet for over 20 minutes despite activating the call light. Observations showed multiple staff members, including maintenance employees and a COTA, ignoring the call light. The resident expressed frustration over the delay in assistance, which was confirmed by interviews with staff. The facility's policy emphasized timely responses to call lights, but this was not adhered to in Resident #70's case. Similar issues were noted for Residents #39 and #82, who did not receive adequate personal hygiene care and assistance with adaptive eating equipment as per their care plans.
Facility Lacks Qualified Social Worker for 120+ Bed Requirement
Penalty
Summary
The facility failed to employ a qualified social worker as required for facilities with more than 120 beds, affecting all 96 residents. The job description for the social worker position required a license in the state of practice, a bachelor's degree in social work or a related human services field, and one year of supervised social work experience in a healthcare setting with geriatric individuals. However, the social worker employed held a Bachelor of Arts in Human Services but was not licensed by the state and lacked the required year of supervision. During an interview, the social worker confirmed the absence of a license and the necessary supervised experience.
Infection Control Deficiencies in Wound Care and Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control during wound care for two residents. For Resident #82, the Licensed Vocational Nurse (LVN) did not perform hand hygiene before donning gloves and touched the curtain and bedside table before starting wound care. This resident had a stage three pressure injury and intact cognition. Similarly, for Resident #26, the LVN also failed to perform hand hygiene before donning gloves and touched the curtain and bedside table before starting wound care. This resident had a stage four pressure injury and was moderately cognitively impaired. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Resident #37, who had a pressure injury and a suprapubic catheter. The care plan required EBP, including wearing a clean gown and gloves during high-contact activities. However, observations revealed no signage indicating EBP, and no personal protective equipment (PPE) was available inside or outside the resident's room. The Director of Nursing acknowledged the oversight and the need for proper signage and precautions.
Resident Room Change Without Notice
Penalty
Summary
The facility staff failed to protect the rights of a resident by changing their room without prior notice. The incident involved a resident who was admitted with multiple diagnoses, including diabetes, kidney failure, and anxiety disorder. The resident left the facility for an appointment and returned to find that their belongings had been moved to a different room without any prior notification. This unexpected change led to a misunderstanding between the resident and their former roommate, as each believed the other had requested the move. The facility's policy on room changes requires that residents and their representatives receive timely advance notice of any room changes, including written notice when the change is initiated by the facility. However, in this case, the social worker confirmed that the move was a clinical decision and acknowledged that the resident was not informed beforehand. The facility administrator stated that staff were expected to implement the policy correctly, indicating a failure in adhering to the established procedures for room changes.
Failure to Notify of Fall During Transfer
Penalty
Summary
The facility failed to ensure appropriate notification following a fall during a transfer for one of the residents. The resident, who was cognitively intact and required a mechanical Hoyer lift with two staff members for transfers, reported falling while being transferred from a wheelchair to the bed by a Restorative Nursing Aide and the Maintenance Supervisor. The staff involved did not notify the nurse or physician of the incident, as required, and there was no evidence in the progress notes that a fall had been reported. This oversight compromised the resident's right to prompt assessment and care. The resident had a history of diffuse traumatic brain injury, cerebral infarction, morbid obesity, muscle weakness, and repeated falls. During a skin assessment, the resident was found to have two closed abrasions below the left knee, which were not previously reported to the nurse. The Maintenance Supervisor admitted to assisting with the transfer and stated that the resident's admission paperwork did not indicate the need for a mechanical Hoyer lift. The incident was not properly documented or communicated, potentially placing the resident at risk for unrecognized or untreated injuries.
Failure to Provide Medicare Benefit Change Notification
Penalty
Summary
The facility failed to provide appropriate notification of pending benefit changes to Medicare services for one of the three residents sampled for beneficiary notices. During a review conducted on January 10, 2025, it was found that there was no documentation available for one resident regarding the Beneficiary Notice, which is required for residents discharged within the last six months. The Social Worker, who had been in the position since August 2024, was unable to provide proof of notification letters sent to the resident in question.
Failure to Notify Resident and Representative of Emergency Hospital Transfer
Penalty
Summary
The facility failed to notify a resident and the resident's representative of a facility-initiated emergency transfer to an acute care hospital. This deficiency affected one of the two residents reviewed for hospitalizations. The facility's policy required staff from Social Services or a designee to prepare a written transfer notice to accompany the resident during an emergency transfer. However, a review of the medical record for the affected resident revealed no evidence of such a notice being sent. The resident in question had a medical history that included metabolic encephalopathy, hemiparesis affecting the left side, and a history of cerebrovascular accident (CVA). The resident was transferred to the hospital due to a change in medical condition, but the required written notice of transfer was not completed or sent with the resident. Interviews with facility staff, including an LPN and the DON, confirmed that the notice was not sent, and the DON could not recall whether it was completed, despite having signed the resident's discharge summary.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident and their representative upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the facility's policy on resident transfer and discharge, which mandates that such a notice be given at the time of transfer. The deficiency affected one of the two residents reviewed for hospitalizations, specifically a resident with a medical history of metabolic encephalopathy, hemiparesis, and a history of CVA. The resident was transferred to the hospital due to a change in medical condition, but no evidence of the required written notice was found in the resident's medical record. Interviews conducted with facility staff, including an LPN and the DON, confirmed that the notice of bed-hold policy was not provided to the resident or their representative. The LPN stated that the nurse responsible for the transfer should have completed and sent the notice with the resident as part of the transfer paperwork, and a copy should have been kept in the resident's medical record. The DON acknowledged the oversight, confirming that the notice was neither sent with the resident nor to the resident's representative.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a skin assessment for one resident, which compromised the ability to provide appropriate and timely care. The resident, who had a history of traumatic brain injury, cerebral infarction, morbid obesity, muscle weakness, and repeated falls, was admitted with an intact cognition score. The Admission Minimum Data Set (MDS) noted Moisture Associated Skin Damage (MASD) but no other skin problems. However, a Skin/Wound note created by an LVN on December 25th documented no skin issues, despite the resident having sustained an injury during a transfer on the day of admission. An observation on January 9th revealed two closed abrasions on the resident's left leg, which were not documented previously. The resident reported falling during a transfer on the admission day, resulting in a leg injury. The LVN was unaware of the injury or fall and had not documented the abrasions. The staff member involved in the transfer stated that the resident's admission paperwork did not indicate the need for a mechanical Hoyer lift, and the resident began to slip during the transfer but did not fall. The RNA involved was unavailable for an interview due to suspension.
Delayed Urinalysis Sample Collection
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) sample in a timely manner for a resident. The resident was admitted with multiple diagnoses, including cellulitis, heart disease, anemia, morbid obesity, infection of an unspecified joint, pain, and diabetes with diabetic neuropathy. A physician's order for a UA was dated 1/3/24, but the sample was not collected until 1/10/25. The Director of Nursing Services (DON) confirmed in an interview that the order was executed on 1/10/25, with no reason provided for the delay in obtaining the sample.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities on weekends for two residents and did not assist one resident in attending activities they wished to participate in. Resident #39, who has intact cognitive status and a preference for group activities, was not assisted by staff to get out of bed to attend activities such as bingo, which they expressed a desire to participate in. The resident also mentioned that they were not taken outside to smoke due to their inability to function independently. Resident #58, who has intact cognitive status and a preference for music, books, news, outside activities, and religious activities, reported a lack of activities on weekends. Despite being in the facility for two years, the resident stated that bingo was rarely offered on weekends, leading to boredom. Activity attendance records confirmed that the resident only attended two bingo activities on Saturdays over a three-month period. Resident #78, who also has intact cognitive status and a preference for group activities, religious activities, and music, expressed dissatisfaction with the lack of weekend activities. The resident noted that bingo was not consistently offered on weekends and expressed a desire for church services to be held at the facility on Sundays. The activity attendance records showed that the resident participated in only two weekend activities over three months. Interviews with the Activity Director revealed that weekend activities were not staffed, and only bingo was supervised every other Saturday.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not adhering to its smoking policy, which mandates that residents smoke only in designated areas under staff supervision. Two residents, both with unimpaired cognition, were observed smoking near the facility's front door without supervision. The facility's policy, revised in November 2023, clearly states that smoking is only permitted in designated areas and must be supervised by staff. However, observations on multiple occasions revealed that these residents were smoking unsupervised in non-designated areas. Resident #13, with a medical history of chronic obstructive pulmonary disease and hemiparesis, was observed smoking unsupervised near the facility's front door on several occasions. Despite being aware of the facility's smoking procedures, Resident #13 reported that staff were not adhering to the established smoking times, leading the resident to smoke independently. Similarly, Resident #20, who also has hemiparesis and uses tobacco, was observed smoking unsupervised with Resident #13. The resident reported that the designated smoking area was inaccessible due to snow, forcing them to smoke in non-designated areas. Interviews with facility staff, including an LPN and the Administrator, confirmed that the designated smoking area was the rear patio and that all residents required supervision while smoking. However, the LPN acknowledged the difficulty in monitoring residents due to limited staff availability. The Administrator confirmed the facility's smoking policy but did not provide a clear explanation of how compliance with the policy was ensured. This lack of supervision and adherence to the smoking policy constitutes a deficiency in maintaining a safe environment for residents.
Inadequate Perineal Care Provided to Resident
Penalty
Summary
The facility failed to provide appropriate perineal care to prevent urinary tract infections for one resident. The facility's policy on perineal care, revised in June 2020, outlines specific procedures for cleaning female residents, including washing, rinsing, and drying from front to back using a clean washcloth for each stroke. However, during an observation, a Restorative Nursing Aide (RNA) did not spread the resident's knees apart adequately, which hindered proper cleaning. The RNA claimed that the resident's contracted state prevented proper leg positioning, but a Certified Nurse Aide (CNA) present disagreed, stating that the RNA did not clean the resident properly and could have done better. The resident involved, who was admitted with diagnoses including ventricular tachycardia, overactive bladder, major depressive disorder, and chronic pain syndrome, was cognitively intact and dependent on staff for toileting hygiene. The resident was frequently incontinent for bladder and always incontinent for bowel. The resident's care plan noted behavior issues related to incontinence care, with the resident expressing dissatisfaction with the way staff performed perineal care. In an interview, the resident confirmed dissatisfaction with the care provided, stating that the RNA did not change or wipe them properly and incorrectly applied the brief.
Failure to Administer Prescribed Supplemental Feeding
Penalty
Summary
Facility staff failed to ensure that a resident with a feeding tube received the appropriate treatment and services to maintain nutritional status. The resident, who has a medical history of dementia and a gastrostomy tube, was observed eating only 25% of a lunch meal, yet the staff did not administer the prescribed supplemental tube feeding as per the physician's orders. The orders specified that if the resident consumed less than 50% of meals, Glucerna 1.5 should be administered via the feeding tube, which was not done. Further review of the resident's records showed a pattern of inadequate meal intake without the corresponding administration of the prescribed supplemental feeding. The resident's care flow records indicated low meal consumption on multiple occasions, yet there was no documentation of the PRN Glucerna being administered. An interview with the Director of Nursing revealed that the nursing staff were expected to monitor meal intake and administer the supplemental feeding as needed, which was not adhered to in this case.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed pureed diet menu for two residents, as observed during a meal service. According to the facility's policy on Therapeutic Diets, each food item in a regular diet should be pureed and served separately for residents on pureed diets. On the specified date, the noon menu for residents with pureed diets included pureed BBQ meatballs, mashed potatoes with gravy, pureed buttered peas, pureed brownie, and pureed buttered white bread. However, during the preparation and serving of the meal, the bread was not pureed and served to the residents as required. The Food Services Manager acknowledged that the menu was not followed, resulting in the deficiency.
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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