Sikeston Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sikeston, Missouri.
- Location
- 103 Kennedy Drive, Sikeston, Missouri 63801
- CMS Provider Number
- 265479
- Inspections on file
- 17
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Sikeston Convalescent Center during CMS and state inspections, most recent first.
Unsanitary food storage and kitchen sanitation: Surveyors observed uncovered milk and unlabeled, undated food items in the freezer, along with frozen items that were not sealed, labeled, or dated. They also found a loose freezer door seal, worn and dirty dishwashing supplies, buildup on the dish machine, and dirt, debris, and grease on kitchen floors. The Maintenance Log did not show the loose freezer seal had been addressed, and the DM, MS, and Administrator stated food items should be labeled and dated, equipment cleaned after use, and kitchen floors kept free of grease, dirt, and debris.
Failure to Provide Timely Medicare Non-Coverage Notices: The facility did not issue the required SNF ABN and/or NOMNC at least two calendar days before the end of skilled services for two residents. For one resident, both forms were signed on the same day the notice period began, and for another resident, the NOMNC was signed only one day before skilled services ended. The SSD said he/she was not working at the facility at the time and was unsure why one notice was not completed on time, and the Administrator stated the forms should be signed two days prior to discharge from skilled services.
A resident's death in facility MDS assessment was completed but not electronically submitted for validation in a timely manner, and the assessment was accepted 122 days late. The MDS Coordinator said the assessment had not been submitted for validation, and the Administrator stated it should have been completed and submitted within a timely manner.
Failure to include blood thinner interventions in care plans: Two residents had orders for anticoagulants, but their care plans did not address the medications or include resident-specific, person-centered interventions. One resident had CKD, ecchymoses, cerebrovascular disease, TIA history, and prior cerebral infarction and was receiving apixaban for AFib; the other had COPD and paroxysmal AFib and was receiving rivaroxaban. The ADON, Administrator, and DON stated that residents on blood thinners should be addressed in the care plan with specific interventions.
Failure to Follow EBP and PICC Line Infection Control: An LPN and an RN did not consistently use gowns, hand hygiene, or proper disinfection when accessing a resident’s PICC line for IV daptomycin, and an LPN did not follow EBP during a suprapubic catheter dressing change for another resident. Staff accessed the PICC line without proper port disinfection before and after use, and the dressing change was completed with bare hands after gloves were removed.
A resident with severe cognitive impairment and multiple chronic conditions experienced a significant decline, leading to EMS transport to the hospital. Staff did not notify the resident's designated representative or emergency contact as required by facility policy, instead assuming a family member present would relay the information. There was no documentation of direct notification to the emergency contact.
Two residents with cognitive and physical impairments were left in urine-saturated briefs and did not receive complete incontinent care, as staff failed to clean the pelvic and groin areas during hygiene routines. Multiple residents reported delays in being checked or changed, and staff interviews confirmed that all soiled areas should be cleaned, but this was not consistently done.
Staff failed to change gloves and perform hand hygiene between dirty and clean tasks while providing incontinent care to two residents with cognitive and physical impairments. Both residents required extensive assistance, and the facility did not have a policy addressing infection control practices for incontinent care. Interviews confirmed staff should have changed gloves and performed hand hygiene, but this was not done during observed care.
The facility failed to reconcile narcotics at each shift change for all medication carts, affecting all residents. Numerous missed opportunities for reconciliation were found across various shifts and halls. Interviews revealed the absence of a specific policy on narcotic reconciliation, despite staff acknowledging the best practice of having both on-coming and off-going staff sign the log.
The facility failed to maintain sanitary conditions in the kitchen, with grease buildup on cooking pans and dirty cleaning tools on the dish machine. Food items in the walk-in freezer and dry foods area were improperly stored, with several items opened, unsealed, and without labels or dates. Ice buildup was also observed in the freezer. These practices were contrary to the facility's policies, as confirmed by interviews with the dietary staff and administrator.
A facility failed to document a code status for a resident, despite policy requirements for CPR unless a DNAR or DNR order is present. The resident's medical record, including the face sheet, baseline care plan, and Physician's Order Sheet, lacked this documentation. Interviews with the DON and Administrator confirmed the expectation for code status documentation upon admission.
The facility failed to maintain a safe and homelike environment, with observations of spider webs, dirt, exposed sheetrock, and broken mini-blinds. A resident's Geri-chair was also in poor condition, with worn protective covering. Staff interviews revealed a lack of effective documentation and follow-up on maintenance issues.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident, as required by its policy. The plan, which should address immediate health and safety needs and include initial goals and physician orders, was not completed in the specified timeframe. Interviews with the DON and Administrator confirmed the expectation for timely completion, highlighting a deficiency in meeting professional care standards.
A facility failed to ensure an appropriate diagnosis for a resident prescribed Seroquel for depression, contrary to policy requiring specific conditions for antipsychotic use. The resident, with a history of depression, was on Seroquel and Zoloft, but no behaviors or appropriate diagnosis were documented. The resident experienced excessive sleepiness from Seroquel, leading to refusal of the medication, yet it continued to be administered without proper justification.
The facility exceeded the acceptable medication error rate due to improper insulin administration for two residents. An LPN failed to prime insulin pens and did not leave the needle under the skin for the required duration, leading to a 7.41% error rate. Interviews confirmed the need to prime pens with two units, which was not adhered to.
The facility failed to maintain dumpsters properly, leaving lids open and allowing trash to scatter, including soiled briefs and food waste. Staff interviews confirmed that dumpsters should be closed after use, but observations showed mattresses and foam cups scattered around the area.
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for several residents. An LPN did not wear an isolation gown while performing wound care, despite the facility's policy requiring gowns and gloves to prevent the transmission of multidrug-resistant organisms. Observations showed that EBP signage was often missing, and interviews with staff confirmed the expectation for gown use, which the LPN admitted to forgetting.
A resident with multiple health conditions suffered a left femur fracture due to an improper transfer by a nurse aide who attempted a two-person assist alone without a gait belt. The incident was not immediately reported, delaying medical assessment and intervention.
A resident's family was not notified after the resident's leg was injured during a transfer, resulting in pain and a subsequent hospital transfer for a fractured femur. Despite the resident's complaints and a request for pain medication, the facility failed to inform the family of the incident and the hospital transfer, as confirmed by staff interviews.
Unsanitary food storage and kitchen sanitation
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions. During observations of the walk-in freezer next to the five-shelf metal rack, surveyors found two uncovered glasses of milk that were not labeled or dated, a bag of shredded cheese that was not labeled or dated, and a rubber seal around the door frame that was unattached and hanging loose. In the walk-in freezer located inside the canned/dry goods area, surveyors observed a buildup of ice and frost on a plastic resealable bag of meat patties that was not labeled or dated, another bag of meat patties that was not sealed, and a large brown paper bag of potato fries that was not sealed, labeled, or dated. Surveyors also observed the dishwashing machine with three worn scour pads, a dirty squeegee, an open bottle of testing strips lying sideways on top, and a buildup of a hard white substance on the top and side surfaces. Kitchen floors had dirt and debris under the steam table, under a table with a coffee maker and coffee supplies, under and behind the stove, under and around the deep fryer, and a grease-like substance around the stove and deep fryer area. The Maintenance Log from 01/01/26 through 04/03/26 had no documentation that the unattached rubber seal on the walk-in freezer door had been addressed. During interviews, the Maintenance Supervisor, Dietary Manager, and Administrator stated that kitchen floors should be clean and free of grease, dirt, and debris, kitchen equipment should be cleaned after each use, food items should be labeled and dated when opened and placed back into the freezer, and maintenance issues should be written on the maintenance log.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) in writing at least two calendar days before discharge from skilled services for two residents. The report states that this notice is used to inform a Medicare beneficiary about potential non-coverage and the option to continue services with financial liability accepted by the beneficiary. The facility's policy required written notice in advance when Medicare payment denial or a change in coverage was likely, and required the NOMNC to be issued at least two calendar days before Medicare-covered services ended. For Resident #100, skilled services ended on 10/23/25 after discharge from skilled services on 10/22/25, and both the NOMNC and SNF ABN were issued and signed on 10/22/25, which did not provide the required two-day notice. For Resident #101, skilled services ended with discharge from skilled services on 02/06/26, and the NOMNC was issued and signed on 02/05/26, which also did not provide at least two calendar days' notice. During interview, the Social Services Designee stated he/she was not working at the facility at the time of the discharges and was unsure why Resident #101's NOMNC was not completed in the appropriate timeframe. The Administrator stated the SNF ABN and NOMNC forms should be signed two days prior to discharge from skilled services.
Late Submission of Death in Facility MDS Assessment
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) assessment to the State within 7 days of assessment for one resident, Resident #53. Review of the record showed the resident was admitted, later expired in the facility, and had a death in facility MDS assessment completed, but there was no validation status showing the assessment had been accepted. The assessment was submitted 122 days late. The facility policy titled Resident Assessments stated that MDS data is submitted to iQIES as required and that the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments. During interview, the MDS Coordinator stated the death in facility assessment had been completed but had not been accepted because it had not been submitted for validation. The Administrator stated the resident's MDS death in facility assessment should have been completed and submitted within a timely manner for validation purposes.
Failure to Include Blood Thinner Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement care plans with specific, measurable interventions to meet the individual needs of two residents out of 16 sampled. Review of the facility policy showed that comprehensive person-centered care plans are to include measurable objectives, timeframes, and services needed to attain or maintain the resident’s highest practicable well-being, with interventions based on data gathering and clinical decision making and updated when conditions change. However, the care plans for two residents did not address their blood thinner medications with resident-specific interventions. Resident #7 was admitted with diagnoses including chronic kidney disease, spontaneous ecchymoses, cerebrovascular disease, history of TIA, and cerebral infarction without residual deficits, and had an order for apixaban 5 mg twice daily for atrial fibrillation. Resident #37 was admitted with diagnoses including COPD and paroxysmal atrial fibrillation, and had an order for rivaroxaban 20 mg daily. Their care plans, revised in January 2026, did not address the blood thinner medications or include person-centered interventions. During interviews, the ADON, Administrator, and DON stated that residents on blood thinners should be addressed in the care plan with specific interventions.
Failure to Follow EBP and PICC Line Infection Control
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions and infection control practices during care for a resident with a PICC line and chronic wound. Resident #30 had diagnoses including osteomyelitis, congestive heart failure, peripheral vascular disease, and an acquired absence of toes on the right foot, and had an order to flush the PICC line with normal saline before and after each medication administration. During observation of IV daptomycin administration, an LPN performed hand hygiene and wore gloves but did not put on a gown, removed the disinfection cap, and accessed the PICC line without disinfecting the port before attaching the saline syringe. The LPN flushed the line, connected the IV tubing, and later removed gloves and exited the room without hand hygiene. In a later observation, the same LPN again did not perform hand hygiene or wear a gown, and the PICC line port touched the resident’s pants after being disinfected. The port was not scrubbed for at least 15 seconds, and after flushing, the port was not disinfected before reconnecting the IV tubing. During disconnection, the port was again not disinfected before flushing and before the disinfection cap was applied. An RN later administered the IV medication while wearing gloves but not a gown. The facility also failed to follow EBP during care for a resident with a suprapubic catheter. Resident #75 had diagnoses of COPD and neuromuscular dysfunction of the bladder and had orders for a urinary catheter and suprapubic catheter care every shift. During observation of a suprapubic catheter dressing change, an LPN did not perform hand hygiene, put on gloves, and did not wear a gown. The LPN cleaned the insertion site, removed gloves, performed hand hygiene, then applied the split dressing with bare hands, secured it with tape, dated and initialed the dressing, and exited the room without hand hygiene. The Infection Preventionist, ADON, and DON stated that residents with wounds or indwelling devices such as urinary catheters or PICC lines were on EBP and that staff should wear gowns and gloves for direct care and disinfect PICC line connectors before and after access. The facility policy stated that EBP was to be initiated for residents with wounds or indwelling medical devices, including central lines and urinary catheters, and that gowns and gloves should be available near the room. The policy for peripheral and midline IV catheter flushing and locking also required disinfecting the needleless access device before and after access. Despite these requirements, staff did not consistently use gowns, did not consistently perform hand hygiene, did not consistently disinfect the PICC line port before and after access, and handled the suprapubic catheter dressing with bare hands.
Failure to Notify Resident Representative After Significant Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident's designated representative or emergency contact after a significant change in the resident's condition. Specifically, for one resident with severe cognitive impairment and multiple chronic diagnoses, including diabetes mellitus, Alzheimer's disease, anemia, chronic kidney disease, and COPD, there was no documentation that the resident's representative or emergency contact was notified when the resident experienced a decline in condition. The resident became lethargic, cold, and unresponsive, prompting staff to call EMS, who subsequently transported the resident to the hospital. Despite the presence of a family member at the facility during the incident, the emergency contact listed in the resident's records was not notified, and there was no documentation of any attempt to contact the designated representative. Interviews with staff and administration revealed a misunderstanding, as the administrator assumed the family member present would inform the emergency contact, contrary to facility policy, which requires direct notification by staff. This lapse resulted in a failure to ensure proper communication with the resident's representative during a critical change in the resident's status.
Failure to Provide Complete Incontinent Care and Timely Checks
Penalty
Summary
The facility failed to provide appropriate care and services to two residents who were incontinent of bladder, resulting in both being left in urine-saturated briefs with a strong urine odor. Observations revealed that during incontinent care, staff did not adequately clean the residents' pelvic and groin areas, only washing the buttocks and backs of the legs before applying a clean brief. This incomplete hygiene practice was observed for both residents, despite their care plans indicating a need for extensive assistance with activities of daily living, including toileting and hygiene. Resident #4 had a history of cerebral infarction, hemiplegia, hemiparesis, and vascular dementia, with moderate cognitive impairment and dependence for toileting hygiene. Resident #5 had diagnoses including Parkinsonism, ataxia, spinal stenosis, and hemiplegia, also with moderate cognitive impairment and dependence for toileting hygiene. Both residents were observed to be left in urine-saturated briefs prior to care, and the care provided did not include cleaning of the front and peri areas as required. Interviews with residents indicated delays in being checked or changed, with some residents reporting being left wet for extended periods and staff not returning after call lights were activated. Staff interviews confirmed that all soiled areas should be cleaned during incontinent care, and the DON stated that residents should be checked every two hours if incontinent. However, the facility lacked a specific policy on the timing of incontinence checks, and the observed care did not meet the expected standards for thorough cleaning.
Failure to Follow Infection Control Practices During Incontinent Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during incontinent care for two residents with significant cognitive and physical impairments. Observations revealed that staff, including nurse aides and certified nurse aides, did not change gloves or perform hand hygiene between dirty and clean tasks while providing care to residents who were incontinent of bladder and bowel. Specifically, after unfastening and removing urine-saturated briefs and washing the residents' buttocks and legs, staff proceeded to place clean briefs and secure them without changing gloves or performing hand hygiene in between these steps. Both residents involved had moderate cognitive impairment and required extensive assistance with activities of daily living, including toileting hygiene. The facility also lacked a policy addressing infection control practices during incontinent care. Interviews with the Infection Preventionist and the Director of Nursing confirmed that staff should have changed gloves and performed hand hygiene between dirty and clean tasks, while one staff member was unaware of any mistakes made during the care provided.
Failure to Reconcile Narcotics at Shift Changes
Penalty
Summary
The facility failed to ensure proper reconciliation of narcotics at each shift change for all five medication carts, potentially affecting all residents. The review of narcotic count logs revealed numerous missed opportunities for reconciliation across various shifts and halls. For instance, on A Hall, staff missed 11 out of 44 opportunities during the 7 A.M. - 7 P.M. shift from 11/27/24 to 12/18/24, and 13 out of 44 opportunities during the 7 P.M. - 7 A.M. shift from 12/18/24 to 01/08/25. Similar patterns of missed reconciliations were observed in B Hall, C Hall, D Hall, and the Medication Room Nurse Narcotic Count Log, indicating a widespread issue with narcotic reconciliation practices. Interviews with staff, including a Certified Medical Technician (CMT), the Corporate Nurse, the Director of Nursing, and a Licensed Practical Nurse (LPN), confirmed that the facility lacked a specific policy on narcotic reconciliation documentation. Although it was acknowledged as best practice for both on-coming and off-going staff to sign the narcotic reconciliation log, this was not consistently followed. The Administrator also confirmed the absence of a specific policy, despite recognizing the importance of having two staff sign off for each shift. This lack of policy and inconsistent practice led to the deficiency in narcotic reconciliation.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the food service area, as observed during a survey. There was a buildup of grease and a black substance on several cooking pans stored on metal shelf racks, and a white substance on the dish machine. Additionally, dirty cleaning tools and debris were found on top of the dish machine, and soiled blankets were on the floor in front of it. These conditions indicate a lack of proper cleaning and sanitization of kitchen equipment, which is contrary to the facility's policy requiring daily cleaning and sanitization. Furthermore, the facility did not properly store food items in the walk-in freezer and dry foods area. Several food items, including mozzarella cheese, sliced cheeses, and various frozen goods, were found opened, unsealed, and without labels or dates. The walk-in freezer also had significant ice buildup on the floor and under metal racks. The facility's policy mandates that all foods be sealed, labeled, and dated once opened, and that the freezer be free of ice buildup. Interviews with the Assistant Dietary Manager, Dietary Manager, and Administrator confirmed that these practices were expected but not followed, leading to the observed deficiencies.
Failure to Document Code Status for a Resident
Penalty
Summary
The facility failed to document a code status for a resident outside the sample of 17 residents, with a total facility census of 66. The facility's policy on Cardiopulmonary Resuscitation (CPR) requires that CPR be provided unless there is a physician's order for no CPR, such as a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) order. However, the policy did not address the documentation of code status throughout the resident's medical record. Upon review, it was found that the medical record of a resident admitted with diagnoses including a urinary tract infection, altered mental status, and cerebral infarction, lacked documentation of a code status on the face sheet, baseline care plan, Physician's Order Sheet (POS), and care plan. Interviews with the Director of Nursing (DON) and the Administrator revealed that both expected the code status to be documented on the baseline care plan upon a new resident's admission. If not documented there, it should be present on the face sheet, POS, and care planned. The absence of this documentation indicates a failure to adhere to the facility's expectations and policy regarding the documentation of code status, which is crucial for ensuring appropriate emergency care decisions are made for residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. Over several days, surveyors noted a buildup of spider webs and dirt on the outside ceilings of the awnings at the front entrance and near the personnel dining room and kitchen. Inside the facility, rooms were observed with exposed sheetrock, peeled paint, and dark scuff marks on the walls. Additionally, broken slats were noted on a mini-blind in one of the rooms. These conditions were not documented in the maintenance log, indicating a lack of monitoring and timely addressing of environmental concerns. Resident #4's equipment was also found to be in poor condition, with the protective covering worn off and rough edges on the left-side armrest of their Geri-chair. This was observed while the resident was using the chair in the dining room, potentially affecting their comfort and safety. Interviews with the Maintenance Supervisor, Administrator, and Housekeeper A revealed that there was an expectation for staff to document environmental issues in a maintenance log, but this was not being done effectively. The maintenance and housekeeping staff were responsible for addressing these issues, but the lack of documentation and follow-up led to the deficiencies observed.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, identified as Resident #9, which is a requirement according to the facility's policy. The baseline care plan is intended to address the resident's immediate health and safety needs and should include instructions for effective, person-centered care that meets professional standards. The policy specifies that this plan must include initial goals based on admission orders, discussions with the resident or their representative, and physician orders. However, the baseline care plan for Resident #9 was not completed within the required timeframe, as evidenced by the medical record showing the plan dated after the 48-hour window. Interviews with the Director of Nursing (DON) and the Administrator confirmed the expectation that a baseline care plan should be completed within 48 hours of a new admission. Both acknowledged that the plan should reflect pertinent information regarding the resident's care areas. Despite these expectations, the facility did not adhere to its policy, resulting in a deficiency in meeting the professional standards of quality care for Resident #9.
Inappropriate Use of Psychotropic Medication Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for Resident #45. The resident was prescribed Seroquel, an antipsychotic medication, for depression without proper documentation of behaviors or an appropriate diagnosis. The facility's policy requires that antipsychotic medications be used only for specific conditions as documented in the Diagnostic and Statistical Manual of Mental Disorders, and Seroquel was not indicated for the treatment of insomnia or depression in this case. Resident #45 had a medical history of congestive heart failure, type 2 diabetes mellitus, muscle weakness, and insomnia. The resident was on several different depression medications in the past without success and was started on Seroquel along with Zoloft to improve symptoms. However, there was no documentation of behaviors or an appropriate diagnosis for the use of Seroquel. The resident's diagnosis was later corrected to major depressive disorder, but the pharmacy consultant noted that Seroquel was not indicated for the treatment of insomnia or depression. Interviews with facility staff revealed that the resident had not exhibited any behaviors that would warrant the use of Seroquel. The resident reported that the medication caused excessive sleepiness, leading to refusal of the medication. The Director of Nursing acknowledged that the recommendations from the pharmacy consultant were sent to the physicians, but the issue persisted. The facility staff had requested a decrease in the Seroquel dosage due to the resident's complaints, but the medication was still being administered without a proper diagnosis.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.41% due to errors in insulin administration for two residents. The errors were observed during medication administration for two residents, where the Licensed Practical Nurse (LPN) did not follow the manufacturer's instructions for priming the insulin pens and did not leave the needle under the skin for the recommended duration. Specifically, the LPN administered insulin without priming the pen with the required two units and removed the needle from the skin too quickly, contrary to the instructions for both the Humalog and Fiasp insulin pens. Resident #7 had orders for insulin aspart to be administered subcutaneously before meals, with a specific sliding scale based on blood sugar levels. During an observation, the LPN administered 9 units of insulin aspart but failed to prime the pen and did not leave the needle under the skin for the required time. Similarly, Resident #16 had orders for Humalog insulin with a sliding scale, and the LPN administered 3 units without priming the pen and removed the needle too soon. Interviews with the LPN, another nurse, and the Director of Nursing confirmed the requirement to prime the insulin pens with two units before administration, which was not followed in these instances.
Improper Disposal and Maintenance of Dumpsters
Penalty
Summary
The facility failed to ensure that the dumpsters were closed and maintained properly to prevent pest access and contain garbage. Observations over several days revealed that the dumpster lids were left open, with visible trash including boxes, trash bags, soiled briefs, gloves, and scattered food. Additionally, a bed mattress and a box spring mattress were found on the ground near the dumpsters, along with scattered white foam cups and bowls. Interviews with various staff members, including the Assistant Dietary Manager, Dietary Manager, Maintenance Supervisor, and the Administrator, confirmed that staff were expected to close the dumpster lids after discarding trash. The Maintenance Supervisor was responsible for the upkeep of the outside grounds, and the Administrator expected no debris or large items to be left around the dumpsters. Housekeeper A also stated that staff should always close the dumpster lids after discarding trash.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for several residents, as observed during a survey. The facility's policy on EBP, which is designed to prevent the transmission of multidrug-resistant organisms, requires the use of gowns and gloves during high-contact resident care activities, such as wound care. However, during observations, it was noted that the Licensed Practical Nurse (LPN) did not wear an isolation gown while performing wound care on multiple residents, despite the presence of wounds that required such precautions. For Resident #60, the LPN did not wear an isolation gown while changing a dressing on the resident's left heel. Similarly, for Resident #32, the LPN failed to don a gown while cleaning a wound on the coccyx. In both cases, EBP signage was not posted outside the residents' rooms. For Residents #46, #45, and #24, although EBP signage was present, the LPN still did not wear a gown during wound care procedures. Additionally, Resident #3's wound care was conducted without a gown and without EBP signage outside the room. Interviews with facility staff, including the Corporate Nurse, Infection Preventionist, and Director of Nursing, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents with wounds or other conditions requiring EBP. The LPN involved acknowledged forgetting to wear a gown during the wound care procedures. This oversight indicates a failure to adhere to the facility's infection control policy, potentially increasing the risk of transmission of multidrug-resistant organisms.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe transfer for a resident, resulting in a significant injury. A nurse aide attempted to transfer a resident, who required a two-person assist, alone by bear hugging and pivoting the resident. This improper technique led to the resident's left leg twisting and ultimately resulted in a left femur fracture. The resident, who had a history of hypertension, peripheral vascular disease, heart failure, and diabetes mellitus, was dependent on assistance for chair to bed transfers, as documented in their care plan. The incident occurred when the nurse aide, NA A, did not wait for assistance from CNA B and attempted the transfer alone without using a gait belt, which was against the facility's policy. During the transfer, the resident's weight caused them to slide, and their left leg became entangled in the wheelchair, leading to the injury. Despite the resident's complaints of leg pain following the incident, the aides involved did not immediately report the incident to the nursing staff, delaying appropriate medical assessment and intervention. The Director of Nursing (DON) and other nursing staff were not made aware of the incident until much later, which hindered timely monitoring and treatment of the resident's injury. The lack of communication and failure to follow established transfer protocols contributed to the severity of the resident's injury. The incident was not documented in the electronic medical record until several days later, further complicating the situation and delaying necessary medical care.
Failure to Notify Family of Resident's Injury and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's family in a timely manner after an incident where the resident's left leg became entangled in a wheelchair during a transfer, resulting in pain and subsequent injury. The resident, who had diagnoses including hypertension, peripheral vascular disease, heart failure, and diabetes mellitus, was dependent on assistance for chair-to-bed transfers and had a moderate cognitive impairment. Despite the resident's complaints of pain and a request for pain medication, there was no documentation of the family or responsible party being notified of the incident. Further, the facility did not inform the family when the resident was transferred to the hospital due to increased pain in the affected leg, which was later diagnosed as a fractured femur. Interviews with staff revealed that the family should have been notified of both the incident and the hospital transfer, but this did not occur. The responsible party only became aware of the situation when visiting the resident and finding them absent from the facility, having been sent to the hospital without prior notification.
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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