St Joseph Chateau
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Joseph, Missouri.
- Location
- 811 North 9th Street, Saint Joseph, Missouri 64501
- CMS Provider Number
- 265852
- Inspections on file
- 29
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at St Joseph Chateau during CMS and state inspections, most recent first.
A resident with complex psychiatric and medical needs was not allowed to return to the facility after a hospital stay, despite no documented evidence that the facility could not meet their needs. The facility initiated transfer to another SNF without providing a 30-day notice, discharge instructions, or information about appeal rights, and did not document a valid reason for the non-readmission. The guardian was not in agreement with the permanent transfer and reported feeling pressured due to the facility's refusal to readmit the resident.
A resident with complex psychiatric and medical needs was discharged without the facility providing the required 30-day written notice, bed hold policy, discharge summary, or reason for discharge to the court-appointed guardian. The facility also failed to provide a statement of appeal rights, Ombudsman contact information, and did not notify the Ombudsman of the discharge. Documentation and communication gaps were identified throughout the discharge process.
The facility failed to maintain a clean and safe environment, with observations of mold, damaged areas, and pest infestations. Staff and residents reported frequent sightings of mice, and the pest control company's recommendations were not implemented. The lack of adherence to maintenance and cleaning policies contributed to the ongoing issues.
The facility failed to ensure residents were cared for in a dignified manner, with two residents having their skin exposed in common areas and one resident avoiding the dining room due to excessive noise. Staff did not assist in covering exposed skin or addressing noise complaints, impacting the residents' quality of life.
The facility failed to maintain an accurate accounting of resident trust fund accounts by not performing monthly reconciliations. Bank statements from March 2023 through February 2024 showed no documentation of reconciliations, and attempted reconciliations did not match residents' current balances. The Business Office Manager confirmed the discrepancies, affecting funds for 56 residents.
The facility failed to maintain a clean and safe environment, with observations of sticky floors, chipped door frames, mold-like substances, and broken fixtures. Persistent urine odors and gnats were reported, particularly in the 200 hall. Staff and residents confirmed these issues, which had been ongoing for months.
The facility failed to provide written notices of transfer or discharge to residents or their responsible parties, including necessary details and appeal rights. This affected three residents, who were transferred to the emergency room without proper documentation. Interviews revealed a lack of a formal process to notify the Ombudsman of such transfers.
The facility failed to follow professional standards in medication administration and blood sugar monitoring. Staff did not check blood sugars prior to meals for two residents and failed to clarify a Vitamin D3 supplement order before administration. Interviews confirmed that orders must be followed precisely.
The facility failed to assess and maintain bed rails for two residents, leading to potential safety risks. One resident with severe cognitive impairment and hemiplegia, and another with moderate cognitive impairment and a seizure disorder, were observed with bed rails in the up position without proper assessments or physician's orders. Staff were unclear about responsibilities for entrapment assessments and bed measurements.
The facility failed to monitor monthly Medication Regimen Review (MRR) reports and did not ensure timely communication of pharmacist recommendations to physicians, affecting three residents. Delays in addressing recommendations for lab tests and medication changes were noted, with the Director of Nursing acknowledging the need for a faster process.
The facility failed to serve palatable, attractive, and safe food to three residents, with issues including cold temperatures and insufficient portions. Observations and staff interviews confirmed that food temperatures were below the required 135 degrees Fahrenheit, and complaints about cold food and small portions were common.
The facility failed to ensure that pureed foods were prepared in the correct consistency, affecting three residents with dysphagia. The pureed food was too thin and runny, posing a choking hazard. Dietary staff and the registered dietitian confirmed that the food consistency did not meet the required smooth, pudding-like texture.
The facility failed to maintain the kitchen in a sanitary manner, with dirt and debris observed in various areas, undated open food in freezers, and a lack of communication and responsibility for repairs and cleaning. Interviews revealed that staff were unaware of the needed repairs and cleaning, and the maintenance book did not show any requests for the kitchen.
The facility failed to maintain quarterly QAA committee meetings with the required members. The QAA committee met in April, June, October, January, and March, but the Medical Director only attended two of these meetings. The DON was unaware of the QAA and QAPI coordinator, and the Corporate Compliance Nurse indicated that the Administrator was responsible but was unaware of the Medical Director's attendance issues. The facility was in transition to a new Administrator.
The facility failed to follow infection control standards for medication administration when staff touched medications with ungloved hands for two residents. Additionally, the facility did not provide annual Tb testing for three residents, with staff showing a lack of clarity and responsibility regarding the administration and documentation of Tb tests.
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and mice droppings in various areas, including resident rooms and common areas. Staff and residents reported persistent issues, and structural problems were identified but not adequately addressed.
The facility failed to ensure dependent residents received necessary services for personal hygiene. Staff did not provide complete perineal and urinary catheter care to two residents, failing to clean all perineal folds and using the same area of wipes for different parts of the body. The DON confirmed the staff did not follow proper procedures.
The facility failed to supervise a resident with severe cognitive impairment and a history of choking during meals, as required by the care plan. Despite documented needs and staff acknowledgment, the resident was observed eating alone on multiple occasions, leading to a deficiency.
A resident experienced significant weight loss of over 10% in 3 months due to dissatisfaction with cold food and renal diet restrictions. Despite various nutritional interventions and recommendations from the RD, the weight loss continued. Staff and the resident reported issues with small portions and food quality, but these concerns were not effectively addressed by the facility.
Failure to Allow Resident Return and Inadequate Discharge Process
Penalty
Summary
A deficiency occurred when the facility failed to allow a resident to return after a hospital stay, without providing documented evidence that the resident's needs could not be met. The resident, who had a court-appointed guardian, had multiple diagnoses including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of attention-seeking behaviors and statements of self-harm, which were being managed through monitoring, therapy, and medication adjustments. Despite these interventions, the facility decided not to readmit the resident after a psychiatric hospital stay, citing concerns about ongoing suicidal ideation (SI) and the belief that the resident required a higher level of care. The facility initiated referrals to other skilled nursing facilities (SNFs) while the resident was still at the mental health hospital, and ultimately transferred the resident to another SNF without providing a documented reason that the resident's needs could not be met at the original facility. Communication records show that the guardian did not agree to a permanent transfer and expected the resident to return if no alternative placement was found. The facility did not provide a 30-day discharge notice, discharge instructions, or information about the right to appeal or contact the Ombudsman, as required by regulations. The guardian reported feeling pressured to accept the new placement due to the facility's refusal to readmit the resident. Interviews with facility staff, the guardian, and hospital staff confirmed that the facility had previously managed the resident's SI and behaviors with interventions such as one-on-one monitoring and medication adjustments. Staff acknowledged that there was no emergency requiring immediate transfer and that the facility could have continued to care for the resident. The decision to transfer was made without proper discharge planning, documentation, or regulatory notifications, and the accepting SNF was not screened to ensure it could meet the resident's needs. The lack of a documented reason for non-readmission and failure to follow required discharge procedures led to the deficiency.
Failure to Provide Required Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide the required written 30-day notice of discharge, bed hold policy, discharge summary, and the reason for discharge to the resident's court-appointed guardian. Additionally, the facility did not provide a statement of appeal rights, nor did it include the name, address, or telephone number of the Office of the State Long Term Care Ombudsman. The Ombudsman was also not notified of the resident's discharge. The facility was unable to provide its Discharge Policy upon request. The resident involved had multiple diagnoses, including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of psychiatric hospitalizations. On one occasion, the resident was transferred to an emergency room following a suicide hotline call, but there was no documentation of a bed hold notice, appeal rights, or Ombudsman contact information related to this transfer. The guardian did not receive discharge instructions, a recapitulation of the resident's stay, a final summary status, or a reconciliation of medications. Communication records show that the facility decided not to allow the resident to return after a psychiatric hospitalization, citing an inability to provide the necessary level of safety. The guardian was informed of this decision and agreed to a transfer to another skilled nursing facility only after being told the resident could not return. Interviews with facility staff and the guardian revealed conflicting accounts regarding the resident's wishes and the discharge process, but it was confirmed that the required written notifications and documentation were not provided to the guardian, and the Ombudsman was not notified.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of unclean and damaged areas within the facility. Observations included a cracked ceiling with a dark substance at the nurses' station, mold-like substances in various locations such as the activity office and laundry room, and damaged sheetrock in the closet containing the ice machine. Additionally, the kitchen was found to have a sticky floor with food debris, and a mouse was observed stuck to a glue trap under the sink. The facility's pest control program was not effectively implemented, as evidenced by the presence of mice and other pests throughout the facility. Interviews with staff and residents revealed frequent sightings of mice in various areas, including resident rooms, the therapy office, and the activity office. The pest control company had made several recommendations to address structural concerns and sanitation issues, such as sealing holes and cleaning mouse droppings, but these recommendations were not acted upon. The facility's maintenance and cleaning policies were not adequately followed, contributing to the pest control issues. The Director of Maintenance acknowledged the lack of a maintenance person and the ongoing pest control problem. The Administrator was aware of the pest control issue and expected the facility to be clean and comfortable, with staff following the cleaning schedule and reporting cleanliness issues. However, the observations and interviews indicated that these expectations were not met, leading to the deficiency.
Failure to Maintain Resident Dignity and Dining Experience
Penalty
Summary
The facility failed to ensure residents were cared for in a dignified manner, as evidenced by two residents having their skin exposed in common areas. Resident #47, who has severe cognitive impairment and requires substantial assistance with dressing, was observed walking down the hall with exposed skin on the left chest. Despite passing multiple staff members, including CNAs, no one assisted in covering the resident's exposed skin. Similarly, Resident #32, who has a history of mental health diagnoses and requires supervision for dressing, was observed multiple times with their abdomen exposed while in common areas and in bed, without staff offering assistance to cover them up or pulling the privacy curtain in their room. Staff interviews confirmed that residents should not have exposed skin and that they should assist in covering them when noticed, but this was not done in these instances. Additionally, the facility failed to provide a dignified dining experience for Resident #14, who stopped eating in the dining room due to excessive noise from other residents playing music and using cell phones. The resident, who has minimal cognitive loss and requires supervision for ADLs, reported that the noise and occasional bad odors in the facility made it difficult to eat. Staff interviews corroborated the resident's complaints about the noise and odor, with the Housekeeping Supervisor and DON acknowledging persistent odors in certain hallways and the need for tile replacement. These deficiencies highlight the facility's failure to maintain a dignified environment for its residents, as required by their policy on promoting and maintaining resident dignity. The staff's inaction in addressing exposed skin and excessive noise in the dining room directly impacted the residents' quality of life and comfort within the facility.
Failure to Properly Reconcile Resident Trust Fund Accounts
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. Record reviews of the facility-maintained bank statements for account ending in #8793 from March 2023 through February 2024 showed no documentation of reconciliations. Additionally, the attempted reconciliations did not match the residents' current balances at the time of reconciliation. Email correspondence and an interview with the Business Office Manager confirmed that the reconciliations were not performed properly, affecting the funds managed for 56 residents out of a facility census of 62.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of unclean and unsafe conditions. Specific issues included sticky floors, chipped and peeling door frames, dirty and debris-laden floors, and broken fixtures in resident rooms and common areas. Additionally, there were significant cleanliness issues in the dining rooms, hallways, and shower rooms, including mold-like substances, broken tiles, and malfunctioning equipment. These conditions were observed over several days and were corroborated by staff and resident interviews. Residents and staff reported persistent and strong urine odors, particularly in the 200 hall, which were attributed to residents urinating on the floors, mattresses, and in shared bathrooms. The facility's housekeeping and maintenance staff acknowledged these issues but failed to adequately address them. The Housekeeping Director admitted to not tracking or inspecting the completion of deep cleaning tasks, and the Maintenance Director was unaware of several maintenance issues, including loose handrails and broken fixtures. Interviews with residents and staff revealed that the urine odors and cleanliness issues had been ongoing for several months, with some staff resorting to wearing masks due to the strong odors. The facility's Director of Nursing (DON) and Administrator were aware of the problems but had not implemented effective solutions. The presence of gnats in resident rooms further indicated a lack of proper sanitation and pest control measures. Overall, the facility's failure to maintain a clean and safe environment compromised the residents' quality of life and well-being.
Failure to Provide Proper Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to residents or their responsible parties, including the reasons for the transfer, in a language they understood. The notice should have included the effective date of discharge or transfer, the location to which the resident was transferred or discharged, a statement of the resident's appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman. This deficiency affected one of 16 sampled residents, Resident #5, and the facility also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, affecting three residents in total (Residents #5, #13, and #32). The facility census was 62 at the time of the survey. Resident #32, who had cognitive skills intact but required supervision for certain activities, was transferred to the emergency room for a psychiatric evaluation after exhibiting aggressive behavior. The facility did not have a copy of any discharge letter or documentation of the bed-hold letter sent with the resident. Similarly, Resident #5, who had severe cognitive impairment and multiple diagnoses including schizophrenia and hemiplegia, was transferred to the emergency room for evaluation after showing signs of a stroke. The record did not contain a copy of any discharge letter or bed-hold letter documentation. Resident #13, who had no cognitive impairment but had a history of psychotic disorder, anxiety, and depression, was transferred to the emergency room after exhibiting aggressive behavior and refusing redirection. The facility did not have a copy of the notice provided to a representative of the Office of the State Long-Term Care Ombudsman. Interviews with the Social Services Designee and the Director of Nursing revealed that there was no formal process in place to notify the Ombudsman of transfers and discharges, and the Director of Nursing believed that Social Services was handling these notifications as a group.
Failure to Follow Professional Standards in Medication Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure staff followed professional standards of quality in the administration of medications and monitoring of blood sugars for residents. Specifically, staff did not check blood sugars prior to meals for two residents, Resident #32 and Resident #53, and failed to obtain blood sugars on the day ordered by the physician for Resident #53. Additionally, there was no physician's order to check blood sugars for Resident #32, and a Vitamin D3 supplement order for Resident #41 was not clarified before administration. These deficiencies were observed during a survey where staff did not adhere to the facility's medication administration policy, which mandates that medications be administered as ordered by the physician and in accordance with professional standards of practice. For Resident #53, the physician's order required weekly blood sugar checks on Saturdays, but the resident's blood sugar was checked on a different day, and insulin was administered post-breakfast. For Resident #32, there was no physician's order for blood sugar checks, yet the resident's blood sugar was checked after breakfast, and insulin was administered. The resident refused the fast-acting insulin. For Resident #41, a Certified Medication Technician administered Vitamin D3 without clarifying the dosage, despite recognizing the discrepancy in the order. Interviews with staff, including an LPN and the Director of Nursing, confirmed that blood sugars should be obtained before meals and that orders must be followed precisely.
Failure to Assess and Maintain Bed Rails
Penalty
Summary
The facility failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure the bed's dimensions were appropriate for the resident's size and weight. Additionally, the facility did not perform scheduled maintenance of the bed rails for two of the 16 sampled residents. Resident #5, who had severe cognitive impairment, hemiplegia, and a history of falls, was observed with a bed rail in the up position without a physician's order or an entrapment assessment. The resident's care plan and MDS did not indicate the use of bed rails, and staff were unsure of the reasons for the bed rail's presence or who was responsible for the entrapment assessments and measurements. The maintenance supervisor also confirmed the lack of documentation for entrapment assessments and measurements since their tenure began three months prior. Resident #19, who had moderate cognitive impairment, heart failure, dementia, and a seizure disorder, was also observed with bed rails in the up position on both sides of the bed without a physician's order or an entrapment assessment. The resident's care plan indicated the use of bed rails for bed mobility, but there was no documentation of an entrapment assessment. Interviews with staff, including the physical therapy assistant, registered nurse, and maintenance supervisor, revealed confusion and lack of clarity regarding the responsibility for conducting entrapment assessments and measuring bed dimensions. The Director of Nursing was also unsure of the policy and where maintenance documented the measurements. The facility's undated Side Rails Policy required an assessment for risk of entrapment, obtaining a physician's order, ensuring correct installation and maintenance, and inspecting the mattress and bed rails for gaps and areas of possible entrapment. However, the facility did not adhere to these procedures, resulting in the deficiency. The lack of proper assessments, documentation, and maintenance of bed rails posed a potential risk to the residents' safety.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to monitor the monthly Medication Regimen Review (MRR) reports for November 2023 and January 2024, completed by the pharmacist, and did not ensure that recommendations were addressed with Resident #5's physician by midnight of the next calendar day. This affected three residents. For Resident #5, the pharmacist recommended a monthly complete blood count (CBC) due to the resident's Clozapine medication, but the facility did not address this recommendation with the physician until March 2024. Resident #5 had moderate cognitive impairment and required substantial assistance with daily activities, and was on multiple medications including antipsychotics and antidepressants. Similarly, for Resident #19, the pharmacist noted the absence of a Valproic Acid level lab result, which was due in December 2023. The facility did not address this with the physician until March 2024. Resident #19 also had moderate cognitive impairment and required substantial assistance with daily activities, and was on multiple medications including antipsychotics and diuretics. For Resident #39, the pharmacist recommended discontinuing Hydroxyzine for anxiety, but the facility did not address this with the physician until March 2024. Resident #39 had no cognitive impairment but required moderate to substantial assistance with daily activities and was on multiple medications including antidepressants and opioids. During an interview, the Director of Nursing (DON) acknowledged that the process for addressing pharmacist recommendations was slow, taking 7 to 10 days for the physician to review and act on them. The DON mentioned that the pharmacist emails the recommendations, which are then placed in a folder for the physician to review during their weekly visits on Fridays. This delay in addressing the recommendations led to the deficiencies noted in the report. The DON has been working on improving the time frame since May 2023 but acknowledged that the process still needs to be faster.
Failure to Serve Palatable and Safe Food
Penalty
Summary
The facility failed to serve food to the residents that was palatable, attractive, and served at a safe and appetizing temperature. This deficiency affected three residents. Resident #34, who had no cognitive impairment and was independent with activities of daily living (ADLs), was served a bowl of dumplings that was only a quarter full and cold. Resident #47, who had severe cognitive impairment and required extensive assistance, was not offered a meal tray and ended up eating cold food from an uncovered plate in their room. Resident #33, who had intact cognitive skills but required extensive assistance with ADLs, reported that the food received in their room was usually cold. Observations of meal preparation and test trays revealed that the temperatures of the food were below the required 135 degrees Fahrenheit. The pureed green beans were 97 degrees Fahrenheit, the regular hamburger was 98 degrees Fahrenheit, and the pureed chicken was 105 degrees Fahrenheit. Additionally, the pureed green beans were very thin and ran off the spoon like water. Interviews with the dietary staff confirmed that the residents should receive full servings of food and that hot food should be served at temperatures above 135 degrees Fahrenheit. Interviews with various staff members, including a Licensed Practical Nurse (LPN), a Certified Medication Technician (CMT), and a Certified Nurse Aide (CNA), indicated that complaints about cold food and small portion sizes were common among the residents. The Registered Dietitian also confirmed that residents should receive full servings and that pureed food should not be runny. Despite these guidelines, the facility failed to meet the standards for food service, resulting in dissatisfaction and potential health risks for the residents.
Failure to Ensure Proper Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a consistency designed to meet the needs of individual residents. Specifically, the pureed food provided to three residents (Residents #5, #19, and #47) was observed to be too thin and runny, posing a choking hazard. The dietary manager and Cook A were responsible for preparing the pureed meals, but the food consistency did not meet the required smooth, pudding-like texture. This inconsistency was confirmed through observations and interviews with the dietary staff and the registered dietitian, who all acknowledged that the pureed food should not be runny like liquid. Resident #5, who had a history of dysphagia and was on a pureed diet, was served food that was not properly prepared, increasing the risk of choking. Similarly, Resident #19, who also had swallowing difficulties and required a pureed diet, received improperly prepared food. Resident #47, with severe cognitive impairment and a need for a pureed diet due to dysphagia, was also affected. The facility's failure to provide the requested policy on pureed food preparation further highlights the deficiency in ensuring the safety and dietary needs of these residents.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and the kitchen was maintained in a sanitary manner. Observations revealed that the floor under the three-compartment sink, the ceiling above it, and the top of the dishwasher were covered with dirt and debris. Additionally, baseboards and tiles were missing under the dishwasher, and vents in the ceiling above the coolers were dirty. The wheels of the meal carts were also covered with dirt and debris. Further observations showed that the vent and window by the handwashing sink were dirty, the plate warmer had food spatters, and the kitchen ceiling had peeling paint. The dry storage area had bugs in the light and debris on the floor. The chest freezer contained undated open bags of food and was dirty inside, while the upright freezer had dirt and debris on the sides and bottom, and its drawers were cracked and chipped with dirt inside them. Interviews with the Dietary Manager, Maintenance Director, Registered Dietitian, and Administrator revealed a lack of communication and responsibility for maintaining the kitchen's cleanliness and repair. The Dietary Manager acknowledged that the kitchen should be clean and in good repair, with food labeled and dated, and no open containers in the refrigerator or freezer. The Maintenance Director, who had only been at the facility for three weeks, was unaware of the needed repairs and cleaning in the kitchen. The Registered Dietitian and Administrator both expected the kitchen to be clean, sanitary, and in good repair, with proper food storage. However, the maintenance book at the nurse's desk did not show any repair or cleaning requests for the kitchen, indicating a breakdown in the reporting and addressing of maintenance issues.
Failure to Maintain Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance (QAA) committee meetings with the required members. The facility's policy mandates that the QAA committee be interdisciplinary, including the Director of Nursing (DON), the Medical Director or designee, the infection preventionist, and at least three other staff members, and that it meets at least quarterly. Review of sign-in sheets from April 2023 to March 2024 revealed that the committee met in April 2023, June 2023, October 2023, January 2024, and March 2024. However, the Medical Director only attended the meetings in June 2023 and March 2024, and there was no sign-in sheet for the quarter between June 2023 and October 2023. During interviews, the DON was unaware of who was responsible for QAA and QAPI coordination, while the Corporate Compliance Nurse indicated that the Administrator was in charge but was unaware of the Medical Director's attendance issues. The facility was in a state of flux due to the transition to a new Administrator.
Infection Control and Tb Testing Deficiencies
Penalty
Summary
The facility failed to follow infection control standards and guidelines for medication administration when staff touched medications with ungloved hands for two residents. One resident, who had diagnoses including OCD, stroke, and paranoid schizophrenia, was observed receiving Vitamin D and Cranberry tablets that were handled by a Certified Medication Technician (CMT) with bare hands. Another resident, with diagnoses including stroke, aphasia, and Parkinson's disease, was given Depakote Sprinkles that were placed directly on the medication cart surface and handled without gloves by a CMT. Additionally, the facility failed to provide annual tuberculosis (Tb) testing for three residents. These residents had various diagnoses such as dementia, stroke, and coronary artery disease, and their medical records showed that their last Tb tests were administered over a year ago. The Infection Preventionist (IP) and the Assistant Director of Nursing were interviewed, revealing a lack of clarity and responsibility regarding the administration and documentation of Tb tests. The Director of Nursing (DON) confirmed that staff should not handle medications with bare hands or place pills directly on the medication cart without a barrier. The DON also indicated uncertainty about the timing and responsibility for annual Tb testing, highlighting a gap in the facility's infection prevention and control program.
Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and mice droppings in various areas, including resident rooms, the dining room, and common areas. Observations on multiple dates revealed gnats in residents' rooms, the dining room, the hall, the beauty shop, and the front office area. Interviews with staff confirmed the persistent presence of gnats, with one Certified Nurse Aide noting that gnats were always in the building. The Administrator acknowledged delays in addressing the issue and mentioned that pest control had treated a drain where gnats were nesting. However, the problem persisted despite these efforts. Additionally, mice droppings were observed in two residents' rooms, on bedside tables, dressers, floors, and refrigerators. A mouse was also seen running down the hall and through a hole under the exit doors. Interviews with residents and staff indicated that complaints about mice had been made but not adequately addressed. The maintenance supervisor and pest control company manager both noted structural issues, such as gaps in doors and holes in walls, that facilitated the pest problem. Despite recommendations to fix these issues, the facility had not taken the necessary actions, leading to ongoing pest control deficiencies.
Failure to Provide Complete Perineal and Catheter Care
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, staff did not provide complete perineal and urinary catheter care to two residents. For Resident #20, who had long and short-term memory problems, hemiplegia, and was always incontinent of bowel and bladder, the CNA did not properly clean all perineal folds and used the same area of the wipe for different parts of the body. Additionally, the mattress was not cleaned after the resident urinated on it. The care plan indicated that the resident required extensive assistance for toileting due to dementia and hemiplegia. For Resident #33, who had cognitive skills intact but was dependent on staff for toilet use and transfers, the CNA did not anchor the catheter tubing and failed to clean all perineal folds properly. The resident had a urinary catheter and was always incontinent of bowel. The CNA used the same area of a wipe for different parts of the body and did not separate and clean all areas of the skin where urine had touched. The Director of Nursing confirmed that the staff did not follow proper procedures for perineal and catheter care, including not using the same area of the wipe and not anchoring the catheter tubing.
Failure to Supervise Choking Risk Resident During Meals
Penalty
Summary
The facility failed to provide supervision while eating for a resident who is a choking risk, as outlined in the resident's care plan. The resident, who has severe cognitive impairment, dysphagia, and a history of choking episodes, was observed eating alone in their room on multiple occasions without staff supervision. Despite the care plan and staff acknowledgment that the resident requires supervision during meals, the resident was left unsupervised while eating on at least three separate occasions. Interviews with staff revealed inconsistencies in their understanding and execution of the supervision requirement, with some staff unaware of the need for supervision and others failing to follow through on the care plan directives. The resident's care plan, dated 10/23/23, indicated the need for supervision due to right-sided hemiplegia, cognitive deficits, and a history of choking episodes. The resident's Quarterly Minimum Data Set (MDS) dated 2/9/24, confirmed severe cognitive impairment and the need for substantial assistance with ADLs, including eating. Despite these documented needs, observations on 3/26/24, 3/27/24, and 3/28/24 showed the resident eating alone in their room. Interviews with the RN, CNA, and DON confirmed that the resident should not eat without supervision, yet this protocol was not consistently followed, leading to the deficiency noted in the report.
Failure to Prevent Significant Weight Loss in Dialysis Resident
Penalty
Summary
The facility failed to prevent significant weight loss of more than 10% of a resident's body weight in a 3-month period. The resident, who was at nutritional risk and received dialysis, experienced a total weight loss of 23.1 lbs or 15.38% over 90 days. Despite being on a therapeutic diet and receiving various nutritional interventions, the resident continued to lose weight. The resident expressed dissatisfaction with the food, stating it was always cold and that they did not like the renal diet restrictions. Multiple complaints about small portions and the inability to get desired food were also noted by staff and the resident. The facility's policy on weight monitoring required that significant weight changes be reported to the physician, and appropriate interventions be implemented. However, the primary care physician and the Advanced Practice Registered Nurse (APRN) were not aware of the resident's significant weight loss. The Registered Dietician (RD) had made several recommendations to liberalize the resident's diet and provide supplements, but these were not effectively communicated or implemented. The resident's weight continued to decline despite these efforts. Interviews with staff revealed that multiple residents had complained about small portion sizes and cold food, which contributed to weight loss. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged the resident's significant weight loss and the issues with the renal diet but did not take effective action to address these concerns. The Administrator was also unaware of any complaints about portion sizes or food quality, indicating a lack of communication and follow-up on these issues within the facility.
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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