Shepherd Of The Hills Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Branson, Missouri.
- Location
- 996 State Highway 248, Branson, Missouri 65616
- CMS Provider Number
- 265393
- Inspections on file
- 21
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Shepherd Of The Hills Living Center during CMS and state inspections, most recent first.
RN coverage was not maintained for at least 8 consecutive hours per day, 7 days per week, because the facility had multiple weekends with no RN scheduled and, on some days, no RN time logged at all. The DON said the facility relied on the DON, one prn RN, and the MDS RN to fill gaps, but the facility had no specific RN coverage policy and acknowledged it was not always in compliance with the required RN coverage.
Failure to complete CBCs before hire was cited after record review showed two sampled employees did not have documented CBCs before their hire/start dates. The facility’s abuse prohibition policy required FCSR/EDL and CBC screening before any contact with residents, but one DA had a CBC request documented months after hire and one HK employee had no documented completed CBC. The Asst. BOM, DON, QA RN, and Administrator all acknowledged that background checks are to be completed before staff work with residents.
A medication refrigerator in the med room was found at 31 degrees Fahrenheit while storing influenza vaccine, Lantus, and NovoLog that required 36 to 46 degrees Fahrenheit. Temperature logs also had multiple missing entries over several months, and staff interviews showed inconsistent knowledge of the required range and routine monitoring responsibilities.
Staff failed to follow infection control practices during resident care, including EBP and hand hygiene. During wound care for a resident with chronic wounds and a Foley catheter, the ADON and DON did not wear gowns, and the ADON handled the catheter bag, resident gown, and supplies without hand hygiene before changing gloves. During PEG tube medication administration for another resident, an LPN used gloves but no gown while verifying tube placement, flushing a clogged tube, and giving medications. During a diabetic accu-check and insulin administration for a resident with diabetes, a CMT repeatedly donned and doffed gloves without performing hand hygiene.
A resident with severe cognitive impairment, diabetes, atrial fibrillation, reduced mobility, and a history of falls had an incomplete care plan. The plan addressed oxygen use but did not include insulin monitoring, anticoagulant monitoring for Eliquis, high fall-risk interventions, or toileting needs, even though the resident was always incontinent and required extensive assistance with ADLs.
Incomplete Neurological Assessments After Unwitnessed Falls: Nursing staff failed to complete required neurochecks after unwitnessed falls for two residents. One resident had CKD, retroperitoneal hematoma, diabetes, used a walker, and had multiple falls, while the other had dementia, prior fractures, head injury, severe cognitive decline, and high fall risk. Facility records showed missed neurological assessment entries across multiple shifts after falls, and staff interviews confirmed neurochecks were expected after unwitnessed falls to monitor for changes in condition and possible brain bleeds.
A resident with severe cognitive impairment, weakness, reduced mobility, encephalopathy, and type 2 DM was assessed by the RD as needing 2000 plus cc of fluids daily, but intake records showed repeated days below that amount. Surveyors observed the resident sitting for long periods in the day room, TV room, dining room, and activity room without drinks nearby, and staff did not consistently offer fluids even when checking blood glucose, moving the resident, or after toileting when the brief was dry and urine was dark and concentrated. Interviews confirmed the resident needed prompting to drink and that fluids should be offered at least every two hours.
A resident with a history of CHF and COPD was admitted with a cardiac life vest, but staff did not obtain a physician order, include the device in the care plan, or monitor its use as required. Multiple staff interviews revealed a lack of awareness and training regarding the device, and documentation failed to address its application, maintenance, or monitoring, resulting in a deficiency.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility failed to supervise residents during medication administration, leaving medications unattended in rooms, and did not investigate a fall where a resident went down on one knee. Staff admitted to being overwhelmed and not following policies, leading to deficiencies in medication administration and fall investigation protocols.
A resident with moderate cognitive impairment and respiratory issues was allowed to keep and use an albuterol inhaler at their bedside without a documented self-administration assessment or a physician's order. Staff acknowledged the resident's independent use of the inhaler, but the facility's policy requiring an assessment and order was not followed.
The facility failed to fully resolve a resident's grievance regarding $200.00 missing. Only $100.00 was found, and the investigation was stopped prematurely, leaving the grievance unresolved.
The facility failed to ensure that two residents received adequate grooming and personal hygiene care, including nail trimming and shaving. One resident did not receive the scheduled twice-weekly baths or showers. Staff interviews and observations confirmed these deficiencies.
The facility failed to monitor and document the bruit and thrill of a resident's AV shunt for dialysis services. The resident, with ESRD, did not have an order for such checks until identified during a survey. Staff confirmed they did not routinely assess the bruit and thrill, and the DON was unaware of the lack of an order prior to the survey.
The facility failed to ensure the physician reviewed and acted upon medication irregularities reported by a Consultant Pharmacist in a timely manner for a resident with dementia. The pharmacist's recommendations regarding PRN orders and lab tests were not addressed until after the survey was initiated, despite being communicated to the facility staff. The resident was frequently observed sleeping and difficult to awaken.
The facility failed to ensure an expired medication was not stored in a resident's room. A tube of hydrocortisone cream with an expiration date of [DATE] was found in a resident's room. An LPN confirmed the presence of the expired cream, and the DON was unaware of it, despite facility policy requiring periodic checks by CNAs.
The facility failed to ensure a privacy curtain was in place between two residents sharing a semi-private room. Observations over three days showed the curtain was missing, and staff interviews revealed it was removed for washing and not replaced due to a limited supply. The DON and Administrator emphasized the importance of privacy curtains, regardless of residents' cognitive status.
RN Coverage Not Maintained on Weekends
Penalty
Summary
The facility failed to provide the services of an RN for at least eight consecutive hours per day, seven days per week, when it did not have consistent RN coverage on weekends. The facility census was 75, and review of the nurse schedule, timecard reports for all RNs, and the Salaried Personnel - Direct Resident Care Logs for December 2025, January 2026, and February 2026 showed multiple weekend shifts with no RN scheduled and, on some dates, no RN logged time at all. On several Saturdays and Sundays, the only RN coverage came from the MDS Coordinator/RN for less than eight hours, including 6.9 hours, 4.4 hours, 3.8 hours, 4.4 hours, 4.7 hours, and 4.1 hours on different weekends. During interviews, RN K said he/she worked every other weekend and was not sure how RN coverage was scheduled on alternate weekends or when he/she had requested off. The DON said the facility had only one floor RN who worked every other weekend and that they tried to fill alternate weekends with the DON, one prn RN, and the MDS Coordinator/RN, with the DON recording floor time on the salaried time log and the other RNs using the time clock. The DON also stated the facility did not have a policy specific to RN coverage and that they should just follow the regulations. The Administrator acknowledged the facility had a shortage of RNs and that there were gaps on some weekends, so they were not always in compliance with the required RN coverage of eight consecutive hours daily.
Failure to Complete CBCs Before Hire
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after record review and interview showed the facility did not complete criminal background checks (CBCs) for two of ten sampled employees before their hire/start dates. The facility’s Abuse Prohibition Protocol Manual stated that employees and volunteers are to be screened prior to working with residents, including verification of references, licensure, and a CBC, and that the Family Care Safety Registry (FCSR) or Employee Disqualification List (EDL) and CBC must be checked before an applicant has any contact with residents. It also stated that a CBC request and results should be kept in each employee file. Review of the employee records showed Dietary Aide U had a hire date of 11/17/25, but the CBC request was not documented until 02/12/26 and no completed CBC was documented before that date. Housekeeping V had a hire date of 04/14/25, and the facility did not document a completed CBC for that employee. During interview, the Asst. BOM said he/she was responsible for background checks and new employee education, and stated there had been delays and misinformation with the FCSR process. The DON, QA RN, and Administrator all stated that full background checks are to be completed prior to hire and that staff cannot work with residents until the CBC is done.
Medication Refrigerator Stored Drugs Below Required Temperature
Penalty
Summary
The facility failed to maintain the medication storage refrigerator at the recommended temperatures for refrigerated medications and vaccines. The facility policy required refrigerated biologicals and medications to be kept in a securely fastened refrigerator and stored between 36 and 46 degrees Fahrenheit. CDC guidance and package inserts for influenza vaccine, Lantus, and NovoLog also required refrigerated storage between 36 and 46 degrees Fahrenheit and stated that these products should not be frozen. During observation, the medication refrigerator in the medication room contained five boxes of influenza vaccine, 25 pens of Lantus, and 25 pens of NovoLog, and the refrigerator temperature measured 31 degrees Fahrenheit. Review of temperature logs for December 2025 through February 2026 showed multiple missing entries on numerous dates. Staff interviews showed that night shift nursing staff were responsible for checking and documenting refrigerator temperatures, but several staff members were unsure of the exact required range. The ADON, DON, pharmacist, and Administrator all stated that refrigerated medications should be maintained between 36 and 46 degrees Fahrenheit and that staff should monitor and report temperature problems, but the refrigerator was observed below range and the logs were incomplete.
Infection Control Lapses During Wound Care, Tube Feeding Medication Administration, and Accu-Checks
Penalty
Summary
The facility failed to establish and maintain a complete infection control program when staff did not consistently use hand hygiene and Enhanced Barrier Precautions (EBP) during resident care. The report states that staff failed to use proper hand hygiene and EBP during wound care for one resident, during medication administration for another resident with a feeding tube, and during diabetic accu-checks for a resident with diabetes. The facility census was 75, and a sample of 16 residents was reviewed. One resident had chronic venous ulceration of the right lower extremity, a pressure ulcer of the back, and a pressure ulcer of the right buttock. The resident also had a Foley catheter and was identified in the care plan and physician orders as requiring EBP related to the catheter and pressure ulcer. During observed wound care, nursing staff washed hands and donned gloves, but the ADON and DON did not don gowns. While assisting with turning the resident, the ADON picked up and moved the Foley catheter bag with gloved hands, touched the resident gown, covered the resident, and then picked up pen and paper and moved them to the dresser before changing gloves and without performing hand hygiene. Another resident had a PEG tube, was NPO, and received continuous tube feeding and medications through the tube. The resident’s care plan and physician orders identified EBP related to the PEG tube. During observation, an LPN used hand sanitizer and gloves but did not don a gown before entering the room. The LPN verified tube placement, flushed the tube, managed a clogged tube by massaging it, administered medications through the tube, flushed again, and restarted the feeding pump. A third resident with diabetes was observed during an accu-check and insulin administration, during which a CMT donned gloves without performing hand hygiene, completed the blood sugar check, doffed gloves, obtained insulin, donned gloves again without hand hygiene, administered insulin, doffed gloves, and charted results without performing hand hygiene.
Incomplete Care Plan for Resident With Diabetes, Anticoagulant Use, Falls, and Toileting Needs
Penalty
Summary
The facility failed to complete a comprehensive and individualized care plan for one resident with multiple identified needs. Resident #10 had diagnoses including weakness, reduced mobility, atrial fibrillation, hypertension, left femur fracture, diarrhea, constipation, insomnia, depression, encephalopathy, and type 2 diabetes. The resident’s quarterly MDS showed severe cognitive impairment, always incontinent of bowel and bladder, extensive to total assistance needed for bed mobility, transfers, toileting, and locomotion, two or more falls since admission or reentry, insulin injections, and anticoagulant use. The resident’s care plan revised on 01/06/26 addressed impaired gas exchange related to chronic respiratory failure and oxygen administration, but it did not address the resident’s diabetes, insulin use, or signs and symptoms to monitor for blood glucose problems. The care plan also did not address the resident’s anticoagulant use or any monitoring for signs and symptoms related to that medication. In addition, the care plan did not address the resident’s high fall risk or any interventions to prevent falls. The record review also showed that the resident was prescribed Eliquis 2.5 mg twice daily and Novolog FlexPen insulin on a sliding scale before meals and at bedtime. The bowel/bladder assessment showed the resident was always incontinent of bowel and urine, had constipation, was not assessed for a urinary toileting program, and was never aware of toileting needs. Staff interviews reflected that toileting information, fall risk information, anticoagulant monitoring, and diabetic monitoring were expected to be on the care plan, but these items were not included for this resident.
Incomplete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure residents received care and treatment in accordance with professional standards of practice when nursing staff did not complete neurological assessments after unwitnessed falls for two residents. The facility policy on condition changes, including falls, required staff to observe for signs such as lacerations, swelling, changes in consciousness, unequal pupils, weakness, speech disorder, gait change, and other neurological changes, and to monitor the resident frequently until stable. The facility also provided a neurological check worksheet indicating checks should be completed every 15 minutes times 4, every 30 minutes times 2, every hour times 2, and every shift for 72 hours, with nurses’ notes reflecting the assessments. One resident had diagnoses including chronic kidney disease, retroperitoneal hematoma, and diabetes, used a walker, had no cognitive impairment, depressed mood, and multiple falls since admission. After unwitnessed falls documented by nursing staff, neurological checks were started, but the record showed missed neurological assessments on multiple shifts following the falls. The resident’s chart showed gaps in the neurological assessment documentation after falls on 11/23/25, 12/04/25, 12/11/25, and 01/19/26, with several required shift assessments not completed. The second resident had diagnoses including dementia, history of hip fracture, history of neck fracture, and head injury, with significant memory loss, severe cognitive decline, impaired transfers, and high fall risk. After an unwitnessed fall in the resident’s bedroom with a cut on the back of the hand, the fall report directed staff to complete neurochecks for 72 hours, but the neurological check section was left blank. The progress notes did not show the required ongoing assessments during the 72 hours after the fall, and only a later note documented pupils equally reactive and responsive to light. Staff interviews confirmed that neurological checks were expected after unwitnessed falls and were important to identify changes in condition and possible brain bleeds.
Failure to Consistently Offer Fluids to a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate fluid intake for a resident who was assessed by the RD as needing 2000 plus cc of fluids per day and who had diagnoses including weakness, reduced mobility, encephalopathy, and type 2 diabetes. The resident’s quarterly MDS showed severe cognitive impairment, and the care plan identified the resident as at risk for inadequate oral intake with directions to observe intake of food and fluids, update preferences, and offer snacks between meals. The facility policy on hydration stated that water should be distributed each shift, assistance should be given to residents unable to drink independently, and between-meal hydration programs should promote fluid intake. The resident’s intake and output records showed multiple days of fluid intake below the RD’s suggested amount, including totals of 1420 cc, 1220 cc, 1460 cc, 1130 cc, 1300 cc, 1460 cc, 860 cc, and 480 cc. On observation, the resident spent extended periods sitting in a wheelchair in the day room, common TV room, dining room, and activity room without drinks nearby. Staff observed by surveyors did not consistently offer fluids while the resident remained in these areas, including when an LPN checked blood glucose and when a CNA moved the resident from one area to another. During the observation, the resident was eventually provided drinks at lunch, including Kool-Aid, coffee, and a shake supplement, and staff prompted and assisted with eating. Later, after the resident was taken to the bathroom, the brief was dry and the urine was described as dark and concentrated. Staff then returned the resident to the wheelchair and again did not offer a drink. Interviews with CNAs, NAs, an LPN, the DON, and the Administrator confirmed that the resident needed prompting to drink, that fluids should be offered at least every two hours, and that staff would expect residents in day room or activity room areas to be passed water during shifts.
Failure to Obtain Physician Order and Care Plan for Cardiac Life Vest
Penalty
Summary
The facility failed to obtain a physician order, develop a care plan, and monitor the use of a cardiac life vest for one resident with a history of congestive heart failure and chronic obstructive pulmonary disease. Upon admission, the resident was wearing a cardiac life vest, but staff did not address its use in the admission assessment or care plan. Nursing progress notes mentioned the presence of the life vest, but there was no documentation in the physician progress notes or the physician order sheet regarding its use, application, battery changes, cleaning, or monitoring requirements. Interviews with various staff members, including LPNs, CNAs, the MDS Coordinator, the ADON, and the DON, revealed a lack of awareness, training, and experience regarding the care and monitoring of cardiac life vests. Staff consistently stated that a physician order and care plan should have been in place for the life vest, including instructions for skin assessments, battery changes, and monitoring. However, none of these actions were documented or implemented for the resident in question. The deficiency was further evidenced by the absence of any mention of the cardiac life vest in the care plan and the lack of staff education on its use. The resident's use of the device was only discovered after admission, and staff relied on the resident to manage aspects of the device, such as battery changes. The facility's policies required individualized care planning and current physician orders for all treatments and devices, but these were not followed in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Medication Administration and Fall Investigation Deficiencies
Penalty
Summary
The facility failed to ensure nursing staff supervised residents during medication administration, resulting in medications being left unattended in residents' rooms. For instance, Resident #51, who was cognitively intact, had a cup containing three white pills left in their room. The resident admitted to falling asleep before taking all their medications. Similarly, Resident #33, who had moderate cognitive impairment, had a medication cup with several tablets left in their room. The Certified Medication Technician (CMT) admitted to leaving the medications, trusting the resident would take them, despite knowing the policy against it. Additionally, Resident #46, with moderate cognitive impairment, had various medications left at their bedside, which the resident did not know why they were there. The Licensed Practical Nurse (LPN) confirmed that medications should not be left at the bedside. Resident #7, who was cognitively intact, also had multiple medications left at their bedside, which the LPN acknowledged should have been stored in the treatment cart instead of the resident's room. The facility also failed to identify and investigate a fall for Resident #48, who had moderate cognitive impairment and was at risk for falls due to COPD exacerbation. The resident reported getting tangled in their oxygen tubing and going down on one knee but managed to get up and into bed. The LPN did not consider this incident a fall because only one knee touched the ground, contrary to the facility's policy that any knee touching the ground should be considered a fall. As a result, no fall assessment or documentation was completed for this incident. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that medications were sometimes left unattended due to staff being overwhelmed with their workload. The DON and Administrator both emphasized that medications should not be left at residents' bedsides and that any fall, including one where a knee touches the ground, should be investigated and documented according to the facility's policies. The failure to follow these policies led to deficiencies in medication administration and fall investigation protocols.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure staff assessed a resident to determine if they were clinically appropriate and safe to self-administer medications before allowing them to do so. Specifically, Resident #30, who had moderate cognitive impairment and was diagnosed with acute respiratory failure, hypoxia, hypercapnia, and acute bronchitis, was allowed to keep and use an albuterol inhaler at their bedside without a documented self-administration assessment or a physician's order for self-administration. The resident's care plan did not address their ability to self-administer medications, and there was no documentation of a self-administration evaluation in the resident's observation history. During interviews, staff members, including a Certified Medication Technician and the Director of Nursing, acknowledged that the resident had an inhaler at their bedside and administered it independently. However, the Director of Nursing confirmed that no residents in the facility had been approved to self-administer medications, and a self-administration assessment should have been completed and documented in the electronic medical record. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration, which were not followed in this case.
Failure to Fully Resolve Resident Grievance
Penalty
Summary
The facility failed to resolve a grievance and document the full resolution for a resident who reported $200.00 missing. The resident, who was cognitively intact and had multiple diagnoses including chronic diastolic heart failure, acute kidney failure, anemia, type 2 diabetes mellitus with hyperglycemia, and chronic pain syndrome, initiated a grievance on 02/05/24. The facility's grievance policy required a thorough investigation and a written decision within 30 days. However, the investigation was incomplete as only $100.00 was found, and the remaining $100.00 was not accounted for. The Director of Nursing (DON) and the Social Worker (SW) stopped the investigation after locating part of the missing money and did not continue efforts to resolve the grievance fully. Interviews with the resident, DON, and SW revealed that the facility did not follow through with the grievance process as outlined in their policy. The resident confirmed that $100.00 was still missing and that no further action was taken by the facility. The SW, who served as the grievance coordinator, admitted to stopping the investigation after some of the money was found and did not document a full resolution. This failure to fully investigate and resolve the grievance led to the deficiency noted in the report.
Failure to Provide Adequate Grooming and Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that two residents received adequate grooming and personal hygiene care. Specifically, the staff did not provide nail care and did not shave the facial hair of the two residents. Additionally, one resident did not receive the scheduled twice-weekly baths or showers in March 2024. The facility's policy on Activities of Daily Living (ADL) did not address shaving or nail care, and the Certified Nursing Assistant (CNA) job description, although dated May 2006, did not explicitly include these tasks either. Resident #12, who had diagnoses including weakness, chronic pain, and aphasia, was dependent on staff for bathing and required assistance with personal hygiene. The resident's care plan did not include specific interventions for personal hygiene needs. Observations and interviews revealed that the resident had long nails and facial hair that needed trimming. The last documented shower for this resident was on March 14, 2024, and staff did not document nail or shaving care on that day. Interviews with CNAs and LPNs indicated that the resident did not refuse ADL care, but the staff failed to provide the necessary grooming services. Resident #72, who had diagnoses including pain, reduced mobility, and osteoarthritis, needed assistance with showers and personal hygiene. The resident's care plan also lacked specific interventions for personal hygiene. Observations and interviews showed that the resident had long fingernails and facial hair and did not receive the scheduled showers. The resident reported receiving a shower only once a week and not being offered nail trimming or shaving. Staff interviews confirmed that the resident did not always refuse showers, but the staff failed to provide adequate bed baths, nail trimming, and shaving as needed.
Failure to Monitor and Document AV Shunt for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document the bruit and thrill of a resident's arteriovenous (AV) shunt for a resident requiring dialysis services. The facility's policy required daily checks and documentation of the thrill sensation at the AV shunt site, but this was not done for Resident #61. The resident, who had end-stage renal disease (ESRD) and received dialysis three times a week, did not have an order to check the bruit and thrill until it was added during the survey. Staff confirmed that they did not routinely assess the bruit and thrill, and the Director of Nursing (DON) was unaware of the lack of such an order prior to the survey. Interviews with staff revealed that while some nurses checked the AV shunt site for signs of infection, swelling, or bleeding, they did not consistently check the bruit and thrill. The resident also confirmed that nursing staff did not routinely use a stethoscope to assess the AV shunt site. The DON and the Administrator both expected an order to be in place for monitoring and documenting the bruit and thrill, but this was not implemented until the survey identified the deficiency.
Failure to Address Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure the physician reviewed and acted upon medication irregularities reported by a Consultant Pharmacist in a timely manner for one resident. The resident, who had diagnoses including non-Alzheimer's dementia and unspecified disorientation, was on multiple medications such as antipsychotics, hypnotics, and opioids. The pharmacist identified several issues with the resident's medication orders, including duplicate PRN orders for lorazepam without specified dosing intervals, a PRN order for Robitussin lacking a dosing interval, and a recommendation for lab tests related to the use of divalproex acid. These recommendations were not addressed by the prescribing physician until after the survey was initiated, despite being communicated to the facility staff in a timely manner by the pharmacist. The resident was frequently observed sleeping and difficult to awaken, which was also noted by the resident's representative during visits. Interviews with the Pharmacy Consultant, Medical Director, DON, and Administrator revealed a lack of awareness and follow-up on the pharmacist's recommendations, leading to the deficiency.
Expired Medication Found in Resident's Room
Penalty
Summary
The facility failed to ensure an expired medication was not stored in a resident's room. Specifically, a tube of hydrocortisone cream with an expiration date of [DATE] was found in Resident #8's room. The facility's policy mandates that all medications must be stored in locked compartments and that no outdated drugs may be retained for use. During an interview, an LPN confirmed the presence of the expired cream and stated they had not previously seen it. The DON also confirmed being unaware of the expired medication and mentioned that CNAs are expected to periodically check for and remove any medications found in residents' rooms.
Failure to Provide Privacy Curtain in Semi-Private Room
Penalty
Summary
The facility failed to ensure a privacy curtain was in place between two residents who shared a semi-private room. Observations over three consecutive days showed that the privacy curtain between the beds was missing. Interviews with staff revealed that the curtain had been taken down for washing and was not replaced due to a limited supply of replacement curtains. The CNA did not recall if there had ever been a privacy curtain and did not consider it a concern due to the poor cognition of both residents. The LPN was unaware of the missing curtain and would have contacted housekeeping or maintenance if informed. The Environmental Supervisor confirmed the curtain was removed for washing and acknowledged the limited supply of replacements. The Director of Nursing and the Administrator both stated that semi-private rooms should have privacy curtains to provide privacy for the residents, regardless of their cognitive status. The Administrator was not aware of the limited supply of privacy curtains and emphasized that a replacement should be hung immediately when one is taken down. The deficiency highlights a lapse in ensuring resident privacy due to inadequate inventory management and communication among staff.
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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