Sherbrooke Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4005 Ripa Avenue, Saint Louis, Missouri 63125
- CMS Provider Number
- 265417
- Inspections on file
- 25
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Sherbrooke Village during CMS and state inspections, most recent first.
Two residents did not receive adequate pain management in line with facility policy. One resident was admitted with a pelvic fracture and hospital discharge orders for multiple pain medications, yet no pharmacologic or non‑pharmacologic pain interventions were administered for many hours after admission, despite documented escalating pain up to 10/10 and descriptions of excruciating pain overnight. Medication orders for acetaminophen, hydromorphone, cyclobenzaprine, and gabapentin were present, but the MAR showed they were not given as ordered, and staff interviews revealed confusion about eKit use, lack of signed narcotic scripts, and failure to secure timely pain control. Another resident with a coccyx pressure ulcer reported significant pain during transfers and wound care, frequently yelling and moaning, while the care plan did not address wound‑related pain and PRN acetaminophen was never administered over multiple opportunities, with hydrocodone‑acetaminophen given inconsistently. CNAs and a CMT reported relaying pain complaints to nursing, but were unsure if pain medications were provided, and wound care had to be stopped due to uncontrolled pain.
Staff failed to consistently treat residents with dignity and to follow the facility’s cell phone policy. A cognitively intact resident with Parkinson’s disease, dementia, and COPD was denied requested assistance to the dining room and was told by a CNA to move using his/her feet despite visible discomfort, until another aide intervened. A resident with severe cognitive impairment and significant neurologic deficits was fed by a CNA who wore earbuds and looked at a cell phone during the meal. Other cognitively intact residents reported that staff frequently used cell phones and headphones in hallways and while providing care, and resident council members described staff turning off call lights while stating they were not the assigned aide, leaving without notifying others, and talking loudly or yelling on the halls at night. Observations and staff interviews confirmed that these actions conflicted with the facility’s stated expectations that residents be treated with respect and that personal cell phones and headphones not be used in resident care areas.
Surveyors found that hot foods were not maintained at the facility’s required temperature standard during observed meal services, with items such as soup, meatballs, cream of wheat, scrambled eggs, and biscuits and gravy all measuring below 135°F. Multiple cognitively intact residents, including individuals with COPD, dementia, quadriplegia, chronic kidney disease, heart failure, diabetes, depression, and anxiety, reported that their meals—especially room trays—were usually or always served cold. These findings conflicted with the stated expectations of the dietary supervisor, administrator, and DON that food be delivered at safe and palatable temperatures.
A cognitively intact resident with Parkinson’s disease, dementia, COPD, and frequent bowel and bladder incontinence, who depended on staff for toileting hygiene, was left soiled and wet for an extended period despite calling out for help. The resident’s call light was wrapped around the bed frame and out of reach, and over more than two hours the resident remained in bed with a strong odor of stool and urine, repeatedly stating they were soiled and had not been checked. When a CNA and an LPN finally entered, they found the brief and bed pad saturated with urine and a large amount of diarrhea, contrary to the care plan and staff statements that incontinent residents should be checked every one to two hours and kept clean, dry, and odor free.
A resident with cognitive impairment, incontinence, and neurogenic bladder used a family-applied condom catheter at night for over a month without any physician orders, care plan interventions, or documented monitoring. Surveyors observed the drainage bag and tubing on the floor, with the condom catheter secured by duct tape. A CNA reported the family applied and removed the device and managed the drainage bag, while nursing staff, including LPNs and the DON, stated they were unaware of the device’s use and that no documentation, skin assessments, or monitoring of urinary output and characteristics had been completed.
Surveyors identified that the facility’s medication error rate exceeded 5%, based on three errors in 27 observed opportunities. A resident with dementia and hypotension received Midodrine without a BP check beforehand, and the CMT administering it did not know the drug’s purpose. Another resident with severe cognitive impairment and multiple comorbidities had two glaucoma eye drop medications ordered, but the care plan did not address the need for eye drops, and the CMT administered both ophthalmic solutions back-to-back without the required pause or proper technique, contrary to facility policy and manufacturer instructions.
A resident with vascular dementia, COPD, and CKD experienced inadequate foot care, resulting in dry skin and a blister on the left foot. Despite physician orders for skin assessments and wound care, there were no orders for lotion or preventive ointments, and the care plan was not updated. Observations showed dry, flaky skin and a raw area on the left foot. Staff were aware of the issues but failed to document or treat the dry skin, and the facility's skin integrity policy was not followed.
A resident with a history of dementia and confusion was found with serious injuries, including a bloodied face, in a LTC facility. Despite the severity and unknown origin of the injuries, the facility failed to report the incident to DHSS within the required two-hour timeframe, assuming it was an unwitnessed fall.
The facility failed to maintain a licensed Administrator, leading to a gap in compliance with regulations. The DBO temporarily filled the role without a license after Administrator A's license expired, and efforts to contract a new Administrator were unsuccessful.
The facility failed to conduct NA registry checks for three out of ten sampled new hires, as required by their abuse prevention policy. Interviews revealed a lack of awareness about the necessity of these checks for non-nursing staff, potentially compromising resident safety.
The facility failed to provide bedtime snacks, offering them only mid-day between lunch and dinner. Residents reported not receiving snacks after dinner, with one experiencing low blood sugar at night. Snacks were stored in cabinets known only to staff, and there was uncertainty about their availability. The DON stated snacks should be available after dinner, but this was not ensured.
The facility failed to follow infection control practices, including not cleaning treatment carts between rooms and neglecting hand hygiene during wound care. Staff did not wear appropriate PPE during high-contact activities with residents on enhanced barrier precautions. These deficiencies were observed despite the facility's policies and expectations for infection control.
A resident with a surgical wound and low blood pressure experienced purulent drainage and elevated temperature, but the facility failed to notify the physician promptly. Despite documentation of the resident's condition, there was a lack of communication between shifts, leading to a delay in medical intervention. Interviews revealed inconsistencies in reporting practices, and the Director of Nursing expected immediate notification of the physician, which did not occur.
A facility failed to clarify medication orders, leading to duplicated doses for a resident with Alzheimer's and GERD. Additionally, another resident with a dehisced surgical incision was not sent to the hospital in a timely manner despite physician orders. Communication lapses and task delegation issues contributed to these deficiencies.
A facility failed to implement a stop date for a PRN psychotropic medication prescribed to a resident with impaired cognition and behaviors. The resident was given Lorazepam without a specified end date, contrary to the facility's policy requiring a 14-day stop date for PRN antianxiety medications. Interviews with the DON and administrator confirmed the oversight, revealing a deficiency in medication management practices.
The facility failed to properly label and store medications, as observed in a survey. An expired Pantoprazole suspension and an undated PPD vial were found in medication room refrigerators. Additionally, temperature logs for medication refrigerators were incomplete, with several missing entries and out-of-range temperatures. Staff interviews revealed lapses in responsibility for checking expired medications and logging temperatures.
The facility did not make the most recent survey and complaint investigation results accessible to residents and visitors. Observations showed no survey results at the entrance, lobby, or receptionist desk, and no signs indicating their location. Residents and staff were unaware of the binder's whereabouts, with suggestions it might be in storage due to lobby construction.
Failure to Provide Timely and Adequate Pain Management for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pain management for two residents in accordance with its own pain management policy. For one resident with a recent pelvic fracture and history of intractable pain, the facility did not administer any pharmacologic or non‑pharmacologic pain interventions for approximately 20 hours after admission from the hospital, despite hospital discharge instructions that included multiple pain medications. The hospital’s After Visit Summary listed scheduled and PRN orders for acetaminophen, cyclobenzaprine, hydromorphone, and gabapentin, with the last doses given shortly before discharge. On admission, the RN documented the resident as alert and oriented with multiple fractures and chronic pain conditions, and noted that medications were verified with the in‑house NP, but only non‑pain‑related changes were made at that time. The electronic physician orders later reflected orders for Tylenol, hydromorphone, cyclobenzaprine, and gabapentin, yet the MAR showed that none of these pain medications were administered on the day of admission or the following day, except for a single gabapentin dose. Overnight, the resident’s pain escalated significantly. A skilled evaluation note documented a pain score of 4/10 with a notation that PRN medication was provided, but the MAR did not show any corresponding administration of ordered pain medications. Subsequent pain level summaries recorded the resident’s pain as 4/10 and then 10/10, and a nurse’s progress note described the resident as in excruciating pain, awake crying most of the night, and frequently using the call light for repositioning. The nurse contacted the on‑call provider about the increased pain and later documented that the NP recommended sending the resident back to the hospital for pain management. Interviews revealed that the admitting RN did not recall the resident complaining of pain and stated that narcotics could not be pulled from the eKit without signed scripts, and that residents needed to understand the facility would not have their pain medications immediately. The night RN stated that if Tylenol had been ordered it would have been given, but could not confirm administration and acknowledged that documentation should have reflected any Tylenol use. The pharmacy vendor reported having no record of the resident, and the DON stated she expected staff to verify medications, obtain signed scripts, and use available alternatives and non‑pharmacologic interventions, which were not documented as occurring. The second resident had a coccyx pressure ulcer and reported pain associated with this wound, but the facility did not consistently implement pain control interventions during wound care. The resident’s MDS showed occasional pain and multiple comorbidities, and physician orders included PRN hydrocodone‑acetaminophen and acetaminophen, along with a pain scale each shift. The care plan addressed risk for pressure ulcer development and skin integrity but did not address pain related to the existing coccyx pressure ulcer. MAR review showed that PRN acetaminophen was not administered for any of 14 possible opportunities, and hydrocodone‑acetaminophen was given only 8 of 12 possible times, including a dose earlier on the day of observation. During wound care and transfers, the resident repeatedly stated that it hurt and described multiple sore spots, yelling and moaning while being turned and while the wound was cleansed. Staff acknowledged that the resident complained of pain frequently and that they reported this to the nurse, but they were unsure whether pain medication was administered. Wound care had to be stopped due to the resident’s pain, and the Wound Nurse stated she would contact the provider for new pain management orders. The DON later stated she expected staff to address residents’ pain comments and administer medications as ordered, which did not occur consistently for this resident during wound treatment.
Failure to Maintain Resident Dignity and Enforce Cell Phone Restrictions
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and appropriate assistance, and failure to enforce the facility’s prohibition on staff use of personal cell phones in resident care areas. One cognitively intact resident with Parkinson’s disease, dementia, and COPD was observed in a wheelchair at the end of a hallway asking a CNA for help to get to the dining room. The CNA refused to push the resident because the wheelchair had no foot pedals, instructed the resident to move using his/her feet, and repeated this direction even as the resident only advanced a few feet and appeared uncomfortable. Another aide ultimately assisted the resident into the dining room. In later interviews, a CNA, an LPN, and facility leadership all stated that staff should assist residents when they ask for help and that residents should be treated and spoken to in a dignified manner. The report also documents multiple instances of staff using personal cell phones and headphones in resident care areas and during direct care, contrary to the facility’s written policy. A resident with severe cognitive impairment and multiple neurologic deficits was being fed in the dining room by a CNA who had earbuds in and was looking at a cell phone while checking a text message. Other cognitively intact residents reported that staff were on their phones frequently, including in hallways and while providing care, and that staff used phones and headphones during care encounters. Observations confirmed that one CNA sat texting on a cell phone in a hallway lounge with multiple residents present, and another CNA sat next to a resident on a couch wearing headphones and looking at a phone, and was later seen in the hallway wearing headphones and looking at the phone. During a resident council meeting, several residents reported prior concerns to administration about staff not treating residents in a dignified manner. They stated that care staff often entered rooms, turned off call lights while saying "I’m not your aide," and left without notifying another staff member that the resident needed care. Residents also reported that staff were often heard laughing, talking loudly, or yelling to one another on the halls during the night shift, and had been observed on their cell phones while providing care. Staff interviews, including with a CNA, an LPN, the Administrator, and the DON, confirmed that the facility’s expectation was that personal cell phones and headphones not be used in resident care areas and that cell phone use should be limited to the break room, underscoring that the observed and reported behaviors were inconsistent with facility policy and resident rights.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure food and beverages were served at safe and appetizing temperatures, as evidenced by multiple temperature measurements and resident interviews. The facility’s undated meal service temperature log required hot foods to be maintained at or above 135°F in the steam table and cold foods at or below 41°F. However, during a lunch observation on 4/8/26 in the memory care unit, soup measured 126.8°F and meatballs measured 129.3°F, both below the required hot-holding temperature. During a breakfast tray observation on 4/9/26 on the 300 hall, cream of wheat measured 80°F, scrambled eggs 109°F, and biscuits and gravy 111.1°F, all below the facility’s stated hot food standard. Interviews with cognitively intact residents further showed a pattern of food being served cold. One resident with COPD, muscle weakness, depression, and anxiety reported that food was always served cold. Another resident with dementia, muscle weakness, and quadriplegia stated that food was normally served cold when eaten in the room. A resident with muscle weakness, seizures, chronic kidney disease, and heart failure reported food was served cold most days. A resident with heart failure, diabetes, chronic kidney disease, and depression said room trays were normally served cold, and another resident with depression, anxiety, and high blood pressure stated the food was always served cold. The Dietary Supervisor, Administrator, and DON each stated they expected food to be served at safe and palatable temperatures, which was inconsistent with the observed temperatures and resident reports.
Failure to Provide Timely Incontinence and Perineal Care
Penalty
Summary
The facility failed to provide timely and appropriate ADL care, specifically perineal care and toileting assistance, to a cognitively intact resident who was frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene. The resident’s care plan directed staff to assist with bathroom use as desired, offer toileting before and after meals and at bedtime, and clean the perineum after each incontinent episode. On the survey day, the resident was heard yelling for a nurse from the hallway, reporting they had been calling for help for about 30 minutes because they needed to use the bathroom. The resident’s call light was wrapped around the bed frame and out of reach, preventing the resident from calling for assistance. Over the course of more than two hours of observation, the resident remained in bed with a strong odor of stool and later of both stool and urine, repeatedly stating they were soiled, wet, and had not been checked on. Staff did not enter the room to provide care until approximately 11:04 A.M., at which time a CNA and an LPN found the resident’s brief and bed pad saturated with urine and a large amount of diarrhea present. The resident stated they had not been changed all night or that morning. Facility staff, including an LPN, a CNA, and the DON, reported that incontinent residents were expected to be checked every one to two hours and to be kept clean, dry, and odor free, indicating that the observed delay of over two hours in responding to the resident’s needs and the condition in which the resident was found did not meet the facility’s stated expectations or policy for perineal care and incontinence management.
Lack of Orders and Monitoring for Family-Applied External Urinary Device
Penalty
Summary
The facility failed to ensure a resident using an external urinary collection device had appropriate physician orders, care instructions, and monitoring. The resident had moderate cognitive impairment, was always incontinent of bowel and bladder, and had diagnoses including stroke and neurogenic bladder. The resident’s MDS did not indicate use of an external or indwelling catheter, and the care plan only addressed bowel and bladder incontinence with interventions such as assisting to the bathroom and cleansing the peri-area after incontinence episodes. There was no care plan focus or interventions related to an external urinary drainage device, and the physician order sheet contained no orders for such a device. Surveyors observed a urinary drainage bag filled with yellow urine in a basin on the floor, with catheter tubing on the floor and a condom catheter attached and secured with grey duct tape. A CNA reported that the resident’s family member had been applying the condom catheter and duct tape every evening for over a month, and that the CNA removed it each morning, but did not empty the drainage bag, leaving that to the family member. Multiple LPNs, including those responsible for the resident’s care, stated they were unaware the resident was using a condom catheter at night and that a family member was securing it with duct tape. The DON also reported being unaware of the device’s use and expected that staff would have notified nursing so that documentation, skin checks, physician orders, monitoring, and family education related to the external urinary drainage device would occur, none of which had been done.
Medication Error Rate Above 5% Due to Improper Midodrine and Ophthalmic Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 11.11% error rate based on 3 errors out of 27 medication administration opportunities observed. One deficiency involved a resident with dementia, hearing loss, and hypotension whose care plan included hypotension management with medications as ordered and monitoring for side effects and effectiveness. The resident had an order for Midodrine 10 mg PO three times daily, but there was no corresponding order to check blood pressure prior to administration. During an observed medication pass, a certified medication technician (CMT) administered Midodrine without taking the resident’s blood pressure beforehand and stated they did not know what Midodrine was used for, later acknowledging they should have taken the blood pressure first. Another deficiency involved improper administration of ophthalmic medications to a resident with severely impaired cognition, maximal ADL assistance needs, and diagnoses including kidney disease, hypertension, Alzheimer’s disease, aphasia, and seizures. The resident had physician orders for Dorzolamide HCl-Timolol ophthalmic solution and Brimonidine Tartrate ophthalmic solution, both to be instilled in both eyes three times daily for glaucoma/ocular pressure, but the resident’s care plan did not address the need or reason for eye drops. The facility’s eye drop administration policy required specific technique, including forming a pouch in the lower eyelid, avoiding contact of the dropper tip with the eye, compressing the tear duct or keeping the eye closed, wiping excess solution, and waiting 10 minutes between different eye medications. During an observed eye drop administration, the same CMT pried the resident’s eyelids open while the resident resisted and instilled Brimonidine solution in both eyes, then immediately proceeded to administer Dorzolamide-Timolol solution without pausing between the two different medications. This technique did not follow the facility’s eye drop administration policy or the manufacturer’s instructions, which required a waiting period between different ophthalmic solutions. The DON stated an expectation that staff follow the eye drop administration policy, including hand hygiene, glove use, proper eyelid positioning, wiping excess solution, and pausing between different eye solutions.
Failure to Provide Adequate Foot Care and Documentation
Penalty
Summary
The facility failed to ensure proper foot care for a resident, resulting in dry skin and a blister on the resident's left foot. The resident, who was cognitively intact and had diagnoses including vascular dementia, COPD, and CKD, had a physician's order for a head-to-toe skin assessment every Thursday and specific wound care for the left foot. However, there were no orders for lotion or preventive ointments for the resident's dry skin. Skin assessments and shower sheets did not document the resident's dry skin, and the care plan was not updated to address the blister or dry skin. Observations revealed that the resident's left foot had a reddened, raw area with blood and peeled skin, while the right foot had dry, flaky skin. Interviews with staff, including a CNA, LPN, and the DON, indicated awareness of the resident's foot wound and dry skin but a lack of documentation and treatment for the dry skin. The DON and Administrator were not aware of the dry skin issue, and the facility's skin integrity policy was not followed, leading to incomplete and inaccurate skin assessments and shower sheets.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of injury of unknown origin to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. A resident was found wandering onto another unit, wearing only a brief, with a cord tied around their waist and a bloodied face. Despite the serious nature of the injuries, which included a laceration on the forehead and nose, and bruising on the right side of the face, the incident was not reported to DHSS as an injury of unknown origin. The resident, who was admitted with diagnoses including atrial fibrillation, paranoia, anxiety, restlessness, agitation, history of falling, closed head injury, and dementia with behaviors, was extremely confused and had an unsteady gait. Staff members, including a CMT and a CNA, observed the resident with blood on their face and hands, but due to a language barrier, the resident could not explain what happened. The facility's investigation determined that the injuries most likely occurred due to a fall, but there was no documentation of the incident being reported to DHSS within the required time frame. Interviews with staff revealed that there was confusion about the nature of the incident, with some assuming it was a fall and others noting the seriousness of the injuries. The Administrator concluded the incident was an unwitnessed fall and did not expect staff to report it to DHSS. However, the lack of certainty about the cause of the injuries and the failure to report them as an injury of unknown origin constituted a deficiency in the facility's reporting procedures.
Failure to Maintain Licensed Administrator
Penalty
Summary
The facility failed to have a licensed Administrator responsible for establishing and implementing policies for managing and operating the facility, which had the potential to affect all residents. The issue arose when Administrator A's license expired, and the Director of Business Operations (DBO) had to step in temporarily. The DBO applied for a Temporary Emergency License (TEL) after Administrator A's last day at the facility, but there was a period between the expiration of Administrator A's license and the issuance of the TEL where the facility did not have a licensed Administrator. During this period, the DBO was on site and serving as the Administrator, although he was not licensed. The facility attempted to contract an Administrator, but the arrangement fell through, exacerbating the situation. Interviews with the Interim Administrator and the DBO revealed that there was confusion and a lack of clarity about who was serving as the Administrator during the gap, and the Interim Administrator expected the facility to adhere to regulations requiring a licensed Administrator.
Failure to Conduct NA Registry Checks for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees were screened for federal indicators of abuse, neglect, or misappropriation of resident property through the Nurse Aide (NA) Registry. This deficiency was identified for three out of ten sampled employees hired since the last survey, despite the facility having hired at least 57 new employees during this period. The facility's Abuse Prevention policy, approved in June 2022, mandates that all employees and volunteers be screened prior to working with residents, including verification of references, certification, license, and criminal background checks. However, the policy was not adhered to, as evidenced by the absence of NA registry checks in the employee files of Employees A, B, and C. Interviews conducted during the survey revealed a lack of awareness and understanding of the requirement to conduct NA registry checks. The Human Resources representative indicated that background checks were completed and stored at the regional office but was uncertain if NA registry checks were necessary for non-nursing staff. The Administrator confirmed that NA registry checks were not performed and was unaware that such checks should have been conducted for non-nursing staff. This oversight in the screening process potentially compromised the safety and well-being of the residents, as the facility did not fully implement its abuse prevention policy.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to provide and offer snacks at bedtime, as snacks were only offered mid-day between lunch and dinner. This deficiency was identified through observations and interviews with staff and residents. The Dietary Manager confirmed that meals were served at specific times, with breakfast at 7:30 A.M., lunch at 12:30 P.M., and dinner at 5:30 P.M. However, residents reported that snacks were not offered after dinner, and one resident mentioned experiencing low blood sugar at night, which was only addressed with pudding. The Activity Director stated that snacks were distributed at 3:00 P.M. during an event called [NAME], but no snacks were routinely offered after dinner unless requested by residents from CNAs. Further investigation revealed that snacks were stored in cabinets by the nurse's station, but only staff were aware of their location. Observations showed that the [NAME] Hall refrigerator contained only health shakes, and the storage cabinets had no snacks. The Dietary Manager mentioned that the dietary department attempted to stock each nursing station every other day, but there was uncertainty about whether snacks were being refilled or if staff and residents were receiving them. The Director of Nursing stated that snacks were supposed to be available after dinner/bedtime, but the current practice did not ensure this availability.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not following established protocols. Staff were observed bringing a treatment cart into an isolation room without cleaning and disinfecting it before moving it to another resident's room. Additionally, during wound care for a resident, staff did not perform hand hygiene between glove changes, failed to disinfect a clean field, and did not sanitize scissors used in the procedure. These actions were contrary to the facility's policies on transmission-based precautions and wound care procedures. Several residents were affected by the facility's failure to implement enhanced barrier precautions (EBP) appropriately. Staff did not wear the required personal protective equipment (PPE) during high-contact activities with residents who had multidrug-resistant organisms or chronic wounds. For instance, a resident with a urinary catheter and another with a PICC line did not receive care with the necessary gown and gloves, as mandated by the facility's EBP policy. The lack of proper signage and communication about isolation and EBP status further contributed to the lapses in infection control. Interviews with facility staff, including the Administrator and Director of Nursing, revealed an expectation for adherence to CDC guidelines and facility policies. However, observations indicated a disconnect between these expectations and actual practices. Staff were not consistently following procedures for cleaning equipment, performing hand hygiene, and using PPE, which are critical components of infection prevention and control in a healthcare setting.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner when there was a change in the drainage from a surgical wound and a change in the resident's blood pressure. The resident, who was alert and oriented, had a history of dependence on renal dialysis and a right hip fracture with intramedullary nailing. The resident's care plan included monitoring the surgical site for signs of infection and reporting any changes to the medical doctor. However, the facility did not adhere to its Clinical Protocol for notifying healthcare providers of clinical problems. The resident experienced purulent drainage from the surgical wound, elevated temperature, and low blood pressure over several days. Despite these significant changes, there was a lack of communication between shifts, and the physician was not notified promptly. The night nurse documented the resident's condition but failed to ensure that the day nurse contacted the physician. The resident's blood pressure readings were consistently low, and the surgical site showed signs of infection, yet these issues were not communicated effectively to the attending physician or the orthopedic surgeon. Interviews with nursing staff revealed inconsistencies in reporting and documentation practices. Some nurses did not receive complete reports from the previous shift, and there was confusion about whether the physician had been notified. The Director of Nursing and Administrator expected staff to notify the physician immediately in case of a change in condition, but this did not occur. The failure to notify the physician in a timely manner resulted in a delay in addressing the resident's medical needs, as evidenced by the eventual decision to send the resident to the emergency room.
Medication Mismanagement and Delayed Hospital Transfer
Penalty
Summary
The facility failed to meet professional service standards by not clarifying medication orders and documenting the same medication in multiple forms, leading to duplicated doses for a resident diagnosed with Alzheimer's disease, unspecified dementia, and GERD. The resident had conflicting orders for pantoprazole, with both tablet and suspension forms being documented as administered. Interviews with LPNs revealed uncertainty about the last administration date due to expired medication and duplicate orders in the electronic system, which had been down for over a month. The Medical Director confirmed the correct order and emphasized the need for staff to verify duplicate orders before administration. Additionally, the facility did not follow physician orders for another resident who required timely hospital transfer due to a dehisced surgical incision with signs of infection. Despite the physician's orders to send the resident to the hospital, the transfer was delayed. Interviews with nursing staff revealed communication lapses and task delegation issues, resulting in the resident remaining at the facility longer than necessary. The DON and Administrator expressed expectations for timely assessment and transfer following physician orders, which were not met in this case. The report highlights significant deficiencies in medication management and adherence to physician orders, impacting resident care. The facility's failure to address duplicate medication orders and ensure timely hospital transfers for residents with urgent medical needs demonstrates a lack of compliance with professional standards and facility policies.
Failure to Implement Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically for a resident with moderately impaired cognition and behaviors such as rejection of care and wandering. The resident, who had diagnoses including stroke, dementia, and malnutrition, was prescribed Lorazepam, an antianxiety medication, on an as-needed basis without a specified stop date. The facility's policy mandates that PRN psychotropic medications should have a stop date of 14 days or less unless a practitioner documents the rationale for an extended order. However, the order for Lorazepam did not include an end date, and the medication was administered multiple times over a three-month period without reevaluation or reordering. Interviews with the Director of Nursing and the administrator confirmed that the facility's standard practice is to have a 14-day stop date for PRN antianxiety medications, with a requirement for reevaluation and reorder. Despite this policy, the resident's PRN Lorazepam order lacked a stop date, indicating a failure in the facility's medication management practices. This oversight was identified during a survey, highlighting a deficiency in the facility's compliance with its own policies and federal regulations regarding the use of psychotropic medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed during a survey. Three out of five medication carts and both medication rooms were inspected, revealing issues in the medication room refrigerators. An expired bottle of Pantoprazole suspension, used for treating heartburn, was found in the medication storage refrigerator for a resident. Additionally, an opened vial of tuberculin purified protein derivative (PPD) solution was not dated, which is necessary to track its usability period. The facility's policies on medication storage and disposal were not adhered to, as evidenced by the expired medications not being discarded and the lack of proper dating on opened medications. The facility's Storage of Medications policy requires nursing associates to maintain medication areas in a clean, safe, and sanitary manner, and to dispose of discontinued or outdated drugs. However, the staff failed to follow these guidelines, as demonstrated by the expired Pantoprazole and undated PPD vial. Furthermore, the facility did not maintain accurate temperature logs for the medication refrigerators. The temperature logs for May and June showed several missing entries and instances where temperatures were out of the acceptable range. Interviews with staff revealed that night shift nurses were responsible for logging refrigerator temperatures, but this was not consistently done. The Administrator was unaware of the missing logs and expected staff to discard expired medications, date opened medications, and log refrigerator temperatures daily.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make the results of the most recent survey and complaint investigations readily accessible to residents, family members, legal representatives, and visitors. Observations on multiple dates revealed that no survey results were displayed at the entrance, lobby, or receptionist desk, and there were no signs indicating their location. During a group interview, residents expressed their inability to locate the survey binder. When residents requested the binder from the receptionist, it could not be found, and the receptionist was unaware of its location, suggesting it might be in a storage room due to lobby construction. The Assistant Director of Nursing and the Administrator both acknowledged that the binder was typically kept in the front lobby but were unsure of its current whereabouts.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
