St Sophia Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 936 Charbonier Road, Florissant, Missouri 63031
- CMS Provider Number
- 265120
- Inspections on file
- 40
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at St Sophia Health & Rehabilitation Center during CMS and state inspections, most recent first.
A CNA confronted a resident and others for being outside to smoke without supervision, leading to a verbal altercation in which both the CNA and the resident yelled and exchanged remarks. During this exchange, the CNA took a metal fork from a meal tray and threw it toward the resident in the hallway, with the facility’s investigation documenting that the fork struck the resident’s arm, though no injury was noted. The resident had no cognitive impairment or documented behavioral symptoms on a recent MDS, and staff accounts varied on whether the resident typically displayed aggressive behavior. Multiple staff, including an RN, CMT, CNAs, and the ADON, stated that throwing a fork or any object at a resident constitutes abuse under the facility’s abuse policy, which defines abuse as the willful infliction of injury or punishment, including hitting or flicking with an object.
Two residents with significant medical and behavioral histories, including PTSD, MS, bipolar disorder, and a tracheostomy, were involved in repeated verbal and physical altercations in which one resident attempted to choke the other and the other resident pulled out the aggressor’s trach, causing a reddened neck and a knee bruise. Documentation and interviews showed conflicting accounts about how many incidents occurred and when, with some staff and leadership aware of only one event and others describing at least two separate encounters and prior verbal conflicts. The facility’s abuse investigation treated the situation as a single incident, did not clearly reconcile differing reports, and left staff unsure of the residents’ history with each other, demonstrating a failure to fully implement the abuse prevention policy’s requirement for thorough investigation of resident‑to‑resident abuse.
A resident with a PICC line and multiple comorbidities, including ESRD and a stage 4 sacral pressure ulcer, had physician orders and a care plan for weekly PICC dressing changes on the left brachial vein. MARs showed the dressing changes as completed on each scheduled date, and a progress note documented a dressing change on the same day as the survey. However, surveyors observed an old, lifting PICC dressing with an illegible date, and the resident could not recall when it was last changed. The ADON later confirmed the dressing appeared old and that the date might have been from a prior month, acknowledging that staff had documented weekly dressing changes as done when they had not been performed, resulting in failure to follow physician orders and professional standards of practice.
A resident with multiple sclerosis, a left tibia fracture, and a history of chronic pain had a standing order for scheduled oxycodone every four hours, but after a pharmacy change the facility failed to administer the ordered opioid for four days because the medication was not in stock and new prescriptions had not been processed. MAR entries and nursing notes documented repeated missed doses and ongoing unavailability of the drug, while the resident reported significant pain and was observed crying and overwhelmed. Staff acknowledged the pharmacy transition issues, reported giving only PRN acetaminophen and anxiety medication, and leadership confirmed that the resident should not have been without the ordered pain medication for that length of time.
The facility failed to honor residents’ financial rights by keeping resident personal funds in the facility’s operating account instead of a separate resident fund account and by not issuing timely refunds. Record review showed that dozens of residents had personal funds, ranging from small amounts to several thousand dollars, held in the operating account, including a large credit balance for a resident who had overpaid for services. Personal fund balance reports for multiple deceased residents were not sent to the state’s Medicaid division until after an investigation began. The BOM reported that a previous BOM had left without processing at least one refund, that refund requests for several residents were only later sent to the home office, and that some residents’ balances had been written off as bad debt rather than refunded.
A resident with multiple comorbidities, including paraplegia and osteoarthritis, had an order for Morphine Sulfate ER 60 mg q12h but no order or assessment to self-administer medications. Surveyors observed a brown pill and water left at the bedside with no staff present, which the resident then self-administered, contrary to facility policy requiring staff to remain until medications are swallowed and prohibiting leaving meds at the bedside. Later, during a skin assessment, an ADON found a white pill under the resident, initially assumed it was morphine, then crushed and disposed of it at the med cart; review of the narcotic box showed the pill was actually Oxycontin, a Schedule II opioid not prescribed to this resident, while another resident on the unit had Oxycontin. Staff interviews confirmed that controlled meds should not be left in the room and that the resident was not known to pocket or spit out medications.
A cognitively intact resident with quadriplegia and other medical conditions remained in a shared room for nearly four hours after a roommate was pronounced dead, while the deceased’s body remained in the room until removal by a funeral home. Staff closed the privacy curtain and likely the room door but did not ask the surviving resident if he/she wished to leave or if he/she was okay. The resident reported feeling very upset and uncomfortable. In interviews, an LPN, a CNA, the Administrator, and the DON all stated that staff are expected to remove or at least offer the option for a roommate to leave the room when a co-resident dies, and the Administrator and DON acknowledged that leaving the roommate in the room under these circumstances was not dignified.
Surveyors found that the facility did not meet professional standards when a resident with multiple comorbidities and a documented nutritional problem experienced significant weight loss and a dietician-requested reweight was never completed or documented, despite an established process for communicating reweight requests to the restorative aide. In a separate case, another resident with liver cancer and Alzheimer’s had oncology-ordered CBC/CMP labs that were marked complete, but the CMP specimen was reported as hemolyzed with instructions to reschedule, and facility staff did not ensure a timely redraw or communicate results to the oncology office, which ultimately had to perform the labs itself after the resident’s follow-up appointment was cancelled for transportation issues.
A resident with hemiplegia, HTN, and a sacral pressure ulcer had no EBP precautions ordered or care-planned despite multiple open areas, contrary to facility policy requiring gowns and gloves for high-contact care such as wound care. During an observed wound treatment, two LPNs performed high-contact wound care: one LPN donned gloves and a gown, while the other wore only gloves and did not use the gown made available, even while holding and positioning the resident during the procedure. The DON and Administrator later stated they expected staff to follow the EBP policy and for both nurses to wear appropriate PPE.
A staff member gave an after-visit summary containing PHI for a resident to the family of another resident, including details such as name, date of birth, and medical information. When notified of the error, the staff member showed indifference and did not retrieve the document, resulting in a breach of confidentiality.
Surveyors found that the facility did not maintain a homelike environment, as evidenced by unswept rooms, protruding screws on furniture, and dirty plates left in resident rooms for days. Additionally, due to a shortage of regular dining plates, residents were frequently served meals on Styrofoam plates, which led to dissatisfaction and complaints about food quality and temperature. Staff and supervisors acknowledged these issues and cited staffing shortages and supply problems as contributing factors.
A resident with opioid dependence and other medical conditions received Oxycodone for pain management. The facility lost one narcotic count sheet for a card of 30 Oxycodone tablets, resulting in no reconciliation for those doses. While the MAR showed administration of the medication, the required controlled substance documentation was incomplete, and staff interviews confirmed the missing record.
A resident with significant mobility and cognitive impairments, including hemiplegia, dementia, and legal blindness, was transferred by two CNAs using a gait belt instead of the ordered mechanical Hoyer lift. The transfer was performed with the wheelchair unlocked, and the resident showed signs of discomfort. Staff interviews confirmed that the resident's care plan and physician orders required use of a mechanical lift for all transfers, but this protocol was not followed.
A facility allowed an LPN, licensed only in Illinois, to work and provide direct care without a Missouri nursing license. The LPN performed duties such as medication administration, wound care, and care for residents with tracheostomies and tube feedings, often without direct supervision. HR did not verify the LPN's Missouri licensure status, and facility leadership was unaware of the issue until it was identified by a state surveyor.
Two residents with histories of aggression were involved in a physical altercation resulting in injury, but staff failed to conduct a thorough investigation or report the incident as required by the facility's Abuse Prevention Policy. Key witnesses were not asked for statements, and the event was not documented or reported to the State Survey Agency. Facility leadership acknowledged the lapse but could not explain the failure to follow policy.
A resident with multiple medical conditions experienced significant unplanned weight loss over a two-month period, but the facility failed to notify the physician or RD as required by policy. Documentation showed missed meal consumption records, lack of follow-up on hospital recommendations for nutritional supplements, and no evidence of assessment or intervention by the RD, despite the resident's ongoing weight loss and expressed concerns.
Staff failed to consistently notify physicians when residents' blood glucose levels exceeded ordered parameters and did not consistently document blood glucose levels or provide explanations for not administering insulin as indicated on the MAR. Several residents with diabetes experienced undocumented or unreported abnormal blood glucose readings, and staff interviews confirmed that required notifications and documentation were not always completed.
Several residents did not have access to oral care supplies or receive assistance with oral hygiene, despite care plans indicating the need for such support. Staff interviews confirmed that oral care was not consistently offered, and supplies were missing from residents' rooms. The DON and other staff acknowledged that oral care should be provided daily, but observations and resident reports showed this was not occurring.
Several residents with mobility limitations and restorative therapy plans did not receive prescribed ROM exercises and restorative interventions as ordered. Staff interviews and documentation revealed that the restorative aide was frequently reassigned to other duties, resulting in inconsistent delivery of restorative services. The DON and therapy staff were aware of the ongoing failure to provide restorative care as planned.
A resident with a history of bipolar disorder and anxiety, who was homeless and their own legal representative, was admitted to the facility and placed on a locked unit after expressing a desire to leave. The facility did not promptly develop a discharge plan, seek timely psychiatric evaluation for decision-making capacity, or document appropriate discharge planning efforts. Social services documentation was incomplete, and staff interviews revealed confusion about policies for guardianship and locked unit placement, resulting in a failure to provide necessary social services.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision, resulting in an increased risk of accidents for residents.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Two residents with cognitive impairment and toileting needs were denied access to their shared bathroom after staff removed the doorknobs, requiring them to rely on staff to access the main bathroom. Despite care plans and staff interviews lacking clear evidence of recent toilet clogging by these residents, both were left without independent bathroom access, leading to incontinence and use of inappropriate alternatives such as urinals and trash cans.
Staff did not maintain a safe, clean, and homelike environment for two residents with moderate cognitive impairment and incontinence issues. Their shared bathroom was left in unsanitary condition with missing doorknobs, soiled towels, and fecal smears, while one resident's room contained a trash can regularly used for urination. Housekeeping and maintenance staff were aware of these issues, and the facility's policy required prompt cleaning and reporting of such concerns.
A resident with severe cognitive impairment and a history of aspiration pneumonia was not provided with the prescribed pureed meat texture diet and nectar-thick liquids, leading to potential choking hazards. The resident's care plan failed to address the risk of aspiration, and staff did not provide adequate supervision during meals, resulting in the resident chewing on non-food items. Interviews revealed a lack of communication and understanding of the resident's dietary needs among facility staff.
The facility failed to maintain a clean and homelike environment for several residents, with issues such as unclean floors, dirty bedding, and empty soap dispensers persisting over multiple days. Residents expressed dissatisfaction, and housekeeping staff were uncertain about cleaning procedures, leading to deficiencies in maintaining a sanitary and comfortable environment.
Surveyors found expired medications and biologicals in two medication rooms and two medication carts at the facility. Expired items included ESwab kits, eye drops, allergy relief tablets, control solution, and zinc sulfate tablets. Staff interviews revealed no single person was responsible for auditing these areas, leading to lapses in compliance with the facility's Medication Storage policy.
The facility failed to maintain cleanliness in the kitchen, with observations of food debris, trash, and dust accumulation in various areas, including the walk-in refrigerator and freezer, kitchen floors, and preparation stations. Staff interviews revealed discrepancies in cleaning practices and expectations, contributing to the unsanitary conditions.
The facility failed to provide adequate ADL care for four residents, resulting in deficiencies in personal hygiene and grooming. A resident with severe cognitive impairment was observed with unwanted facial hair, while another had greasy hair and dirty hands. Two residents wore the same clothing over several days, with one reporting a lack of available clothing. Staff acknowledged expectations for cleanliness and care planning, but these were not met, as evidenced by observations and interviews.
A resident with communication and mobility impairments was left without access to their call light and was not assisted back to bed despite expressing a desire to do so. The resident, who had a history of stroke and required substantial assistance, was observed with their call light out of reach and was kept in a geri-chair against their preference. Staff interviews revealed a lack of adherence to the resident's care plan and rights, as the resident's needs and preferences were not adequately addressed.
A resident admitted to hospice with cerebrovascular disease did not have a significant change MDS assessment completed within the required 14 days. The MDS Coordinator, responsible for assessments, missed the change due to it not being listed on the electronic physician order sheet. The Administrator confirmed the expectation for timely completion of such assessments.
The facility failed to ensure accurate MDS assessments for two residents. One resident's hospice status and life expectancy were not documented, and another resident's fall was omitted from the MDS. The MDS Coordinator, responsible for all assessments, missed these critical details.
The facility failed to transcribe physician orders correctly for two residents, leading to discrepancies in tube feeding administration times. Additionally, a resident received crushed medications without a physician's order, as staff relied on an unofficial list instead of the MAR. Interviews revealed lapses in ensuring orders were accurately reflected in the MAR.
Two residents with COPD experienced deficiencies in oxygen therapy management. One resident self-adjusted their oxygen flow rate without staff awareness, and their pulse oximetry results were not documented. Another resident's nasal cannula was frequently found on the floor, with the oxygen concentrator left running. Staff interviews revealed inconsistencies in documenting and implementing physician orders, and infection control practices were not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices, as required by CMS. Despite EBP signage and PPE availability, staff did not consistently wear gowns during high-contact care activities for residents with central lines, gastrostomy tubes, or wounds. Interviews revealed inconsistent understanding and implementation of EBP protocols among staff.
A facility failed to maintain resident dignity and privacy, as one resident was left exposed during transport and in bed, with full urinals in sight while eating. Another incident involved a staff member making a video call with a resident visible in the background, violating the facility's phone policy and potentially breaching HIPAA. Interviews confirmed these actions were inappropriate and not in line with facility policies.
The facility failed to assess and supervise two residents for self-administration of medications. One resident with fluctuating cognitive status had medications and an inhaler at their bedside without a physician's order. Another resident, capable of using inhalers, lacked physician orders for self-administration. Staff interviews revealed inconsistencies in policy implementation, leading to deficiencies.
The facility failed to maintain accurate records of residents' personal possessions, as observed through interviews and record reviews. Several residents' inventory sheets were incomplete, unsigned, or not updated to reflect current belongings. Staff interviews revealed inconsistencies in the process of documenting and maintaining personal property inventories, leading to discrepancies in residents' personal property records.
A facility failed to obtain written authorization to use a discharged resident's personal funds, resulting in an unauthorized deduction of $875.00 after receiving an updated bill from the resident's co-insurance. The facility did not notify the resident or their family about the additional charges, leading to a balance owed of $103.00. The Business Office Manager and Regional Business Manager acknowledged delays in processing a refund request and a lack of communication with the resident's family regarding the outstanding balance.
A resident was discharged with a credit balance of $772.00, but the facility failed to refund the amount within 30 days. The Business Office Manager sent a refund request to the corporate office, but the process was delayed due to waiting for confirmation of expenses and third-party payments. The Regional Business Manager acknowledged the delay, and the Administrator expected timely refunds.
A resident was readmitted to a facility from a hospital stay, but their medication and treatment orders were not reentered into the EMR for two days, resulting in missed medications. The resident had a history of schizophrenia, anxiety, high blood pressure, and COPD. The nurse completed an assessment and contacted the physician but failed to activate the orders in the EMR, preventing the administration of medications. The DON and Administrator acknowledged the oversight, and the physician confirmed no adverse effects occurred.
A resident with severe cognitive impairment and multiple health issues received incorrect g-tube feeding care, with the machine infusing at 80 ml/hr instead of the ordered 70 ml/hr and not being turned off at the prescribed time. The LPN acknowledged the error, and the facility's leadership confirmed the expectation to follow physician's orders.
A resident with Alzheimer's and schizophrenia, known for elopement risk, left a secured unit unnoticed due to staff's failure to perform visual checks. The resident exited through a tampered window and was found 12 hours later, two miles away. Staff interviews revealed a lack of awareness and adherence to elopement policies.
A resident with colon cancer did not receive prescribed Capecitabine medication due to a failure in documentation and administration processes at the facility. The resident's medical records lacked documentation of medication orders and appointments, leading to missed administrations in December and February. Staff interviews revealed a breakdown in the process of transcribing and auditing medication orders, contributing to the deficiency.
CNA Threw Metal Fork at Resident During Verbal Altercation
Penalty
Summary
The deficiency involves a failure to protect a resident from physical abuse when a CNA deliberately threw a metal fork at the resident during a verbal altercation. The facility’s own Abuse and Neglect Policy defines abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress, and specifically includes corporal punishment and hitting or flicking with an object. On the day of the incident, the CNA was passing lunch trays on the 300 hall near the courtyard door and observed several residents outside smoking during an unscheduled or unsupervised time. The CNA confronted the group about being outside without supervision, and a verbal exchange began between the CNA and the resident. According to the facility’s investigation and multiple interviews, the CNA and the resident engaged in back‑and‑forth yelling and cursing. The CNA reported that the resident began screaming and cussing and walked toward the CNA with a cane, which the CNA perceived as threatening. The CNA stated that as the resident approached, the CNA threw a metal fork taken from a meal tray toward the resident in an attempt to stop the resident’s forward movement. The resident reported that the CNA became angry during the argument, went behind the counter, grabbed a fork, and threw it, striking the resident’s arm near the elbow. The resident stated that he or she blocked the fork with an arm and expressed surprise that staff would throw an object. A nurse (RN E) and a CMT both described hearing or seeing a verbal exchange in the hallway, with the resident and CNA yelling at each other, and confirmed that the CNA threw a fork at the resident while the resident was in the hallway moving toward the nurses’ station. The resident involved had no cognitive impairment documented on a recent MDS and no recorded history of physical, verbal, or other behavioral symptoms directed toward others. Diagnoses included anemia, seizures, and hypertension. Staff interviews were inconsistent regarding the resident’s typical behavior; some staff described the resident as calm and not aggressive, while others stated the resident could be aggressive, intimidating, or have a temper when not getting his or her way. However, the MDS indicated no behavioral symptoms were present. The facility’s investigation documented that the fork made contact with the resident’s arm, though no discoloration or injury was noted and no medical treatment was required. Multiple staff, including CNAs, an LPN, RN E, and the ADON, characterized throwing a fork or any object at a resident as abuse, and the Administrator acknowledged that throwing and yelling at a resident constituted abuse under the facility’s policy.
Failure to Thoroughly Investigate and Track Resident‑to‑Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse and Neglect Policy by not conducting a thorough investigation into resident‑to‑resident physical altercations and by not clearly identifying or tracking multiple incidents between the same two residents. The policy requires protection from abuse, including resident‑to‑resident physical abuse, and mandates thorough investigation of alleged incidents. An investigation document identified a single altercation in which one resident entered another resident’s room, an argument ensued, and one resident attempted to choke the other, resulting in a reddened neck and dislodgement of the aggressor’s inner tracheostomy cannula. The investigation summary concluded that one resident initiated physical contact by attempting to choke the other, that both residents were assessed, and that no significant injuries were found beyond a slightly reddened neck and a bruise to a knee. However, progress notes, resident interviews, and staff interviews describe more than one altercation or conflict between these same two residents, and staff and leadership were inconsistent and uncertain about how many incidents occurred and when they occurred. One resident’s medical record notes an altercation on one date with a slightly reddened neck and no bruising, followed by another note several days later documenting that residents in the hallway reported they were fighting, and that the same resident again reported being choked by the same peer, with a slightly reddened neck observed. The resident later described two separate encounters: an initial episode where the other resident came into the room cursing and was made to leave by a nurse, and a subsequent episode where the same resident returned, blocked the doorway, pushed the resident against the wall, went for the airway, and the resident responded by pulling out the other resident’s tracheostomy. The resident also reported ongoing headache and feeling unsafe around the other resident. The other resident’s record documents being found in the peer’s room holding the inner cannula, reporting that the peer told them to get out of the room, and admitting to trying to choke the peer because they did not like being yelled at. Later documentation shows that this resident’s tracheostomy was found decannulated days after the altercation, with uncertainty about when it had been removed and conflicting accounts between staff, the resident, and the guardian. Interviews with staff and the Administrator show confusion about whether there was one or two incidents, with some staff only aware of a single event and others acknowledging that the resident should not have been allowed back into the room after an initial altercation. The Administrator stated she believed there were two incidents but that they occurred on the same day and that she should have been informed of more than one incident. The ADON acknowledged prior non‑physical problems between the residents involving inappropriate words. This inconsistent awareness and documentation of multiple altercations, and the lack of a clearly defined history between the two residents, demonstrate that the facility did not fully investigate or track all related events as required by its abuse prevention policy. The residents involved had significant medical and psychosocial histories relevant to the incidents. One resident had no cognitive impairment documented on the MDS but had multiple sclerosis, a tibia fracture, depression, PTSD related to prior traumatic experiences, seizures, and asthma, and a care plan identifying a history of sexual, physical, and emotional abuse with a focus on minimizing trauma triggers and promoting de‑escalation. The other resident had diagnoses including diabetes, generalized muscle weakness, bipolar disorder, chronic respiratory failure, and a tracheostomy, with a care plan identifying potential for physical aggression related to anger and poor impulse control. Despite these known conditions and behavioral risks, the facility’s investigation did not clearly reconcile the differing accounts, did not clearly delineate the number and sequence of altercations, and left leadership and direct care staff unsure about the history between the two residents, constituting a failure to implement the abuse prevention policy’s investigative requirements.
Failure to Follow Physician Orders for Weekly PICC Line Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of practice by not following physician orders for a resident’s peripherally inserted central catheter (PICC) line dressing changes. The resident, who was cognitively intact and admitted with diagnoses including end stage renal disease, a stage 4 sacral pressure ulcer, diabetes, depression, muscle weakness, and cognitive communication deficit, had a care plan and physician order specifying that the PICC dressing on the left brachial vein be changed weekly, on the night shift every Thursday, and that the insertion site be kept clean and protected with a sterile dressing. Review of the February medication administration record (MAR) showed the weekly PICC dressing changes were documented as completed on each scheduled date, and the March MAR showed the same weekly schedule. A progress note dated the day of the survey indicated the PICC dressing had been changed that afternoon with no difficulty and that the line remained patent and intact. However, during observation earlier that same day, the resident was seen in bed with a PICC line to the left upper arm, and the dressing date was worn off and illegible, with the dressing lifting at the corners and not adhering properly. The resident was unsure when the dressing was last changed but reported receiving antibiotics through the PICC line. The Assistant Director of Nursing (ADON) confirmed that the PICC dressing should be changed once a week and that the date on the dressing should reflect the prior week, not have an older date. The following day, the ADON reported that when the dressing was changed the previous day, it appeared old and the date was difficult to read, possibly from mid-February or even January, and acknowledged that the date should have been more recent and that staff should not have charted the dressing change as completed when it had not been done. The Administrator and the Registered Nurse Consultant both stated they expected staff to follow physician orders and not document treatments as done if they were not actually performed.
Failure to Provide Prescribed Opioid Pain Medication During Pharmacy Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed opioid pain medication to a resident for four days following a pharmacy change, despite an active physician order for scheduled oxycodone. The resident had a history of pain related to neuropathy, bilateral lower extremity pain, and a left tibia fracture, with care plan goals for adequate pain relief and interventions that included administering analgesia as ordered and monitoring and reporting pain complaints. The physician order, in place since 11/19/25, directed that oxycodone 5 mg, two tablets by mouth every four hours, be given for pain related to the left tibia fracture, and the March MAR showed this medication scheduled at six times per day. Documentation showed the medication was administered at midnight and 4:00 a.m. on 3/1/26, but all subsequent scheduled doses from later that morning through at least the morning of 3/5/26 were marked as not administered. Nursing progress notes repeatedly documented that the oxycodone was not available or not in stock, and that a pharmacy change and need for new prescriptions were preventing administration. Notes on 3/1/26 indicated the medication needed a prescription and was not in stock, and multiple entries on 3/2/26 and 3/3/26 stated that the medication was not available due to a pharmacy change, that new e-prescriptions were required, and that the facility was awaiting medication from the new pharmacy. Additional notes on 3/4/26 continued to document that the oxycodone was not available. During this period, the facility’s own policies required that physician orders be transcribed and implemented in accordance with professional standards and that medications be ordered to ensure prompt delivery, including use of emergency drug supplies or an automatic dispensing unit for first doses when available. The pain management policy also required systematic recognition, evaluation, treatment, and monitoring of pain, and directed nursing to notify the practitioner if pain was not controlled by the current regimen. Resident interviews and staff statements further described the impact of the unavailability of the ordered pain medication. On 3/4/26, the resident, who was in a wheelchair with a boot on the left foot, reported being out of oxycodone for several days since the pharmacy switch and stated they were hurting without the pain pill because of the broken foot. On 3/5/26, the resident was observed in the hallway in a wheelchair, crying and not wearing the boot, and stated feeling overwhelmed and in a lot of pain, reporting that they had asked for pain medication overnight and instead received anxiety medication. A CMT reported giving the resident PRN Tylenol and stated that the resident did not seem to be in pain and had asked for anxiety medication rather than pain medication, while an LPN acknowledged that the resident did seem to be in pain and that the oxycodone was not in the new pharmacy system, but was unsure how long the resident had been without it. The Administrator and the RN consultant both stated that residents should not be without pain medications for four days, and the RN consultant confirmed that the prescription was not received by the pharmacy until 3/4/26 and that being out of the medication since 3/1/26 was not acceptable.
Failure to Maintain Separate Resident Fund Accounts and Issue Timely Refunds
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to manage their financial affairs by not placing resident personal funds in an account separate from the facility’s operating account and not issuing timely refunds. Record review of the facility’s Accounts Receivable Aging Report showed that 39 residents had personal funds, totaling $39,158.17, held in the facility’s operating account rather than in a separate resident fund account. Individual amounts ranged from small balances of a few dollars to larger sums exceeding $11,000 for some residents. One resident had a credit balance of $1,834.00 due to paying for two months of services that should not have been paid, and this credit remained unrefunded for a period of time despite the issue being brought to the Business Office Manager’s (BOM) attention. The report also shows that the facility did not provide Personal Fund Account Balance Reports for multiple deceased residents to the Missouri HealthNet Division Third Party Liability Unit until after a case-managed investigation had already begun. These deceased residents’ personal fund balances were not timely reported as required. During interviews, the BOM acknowledged that a prior BOM had left without processing at least one resident’s refund and that refund requests for several residents had only been sent to the home office later. The BOM further stated that he or she was working with corporate staff to determine why some residents’ balances had been written off as bad debt instead of being refunded, indicating that these residents did not receive refunds of their personal funds when due.
Improper Handling and Administration of Controlled Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oral medication administration and controlled substance policies when handling a resident’s opioid pain medications. The resident, admitted with diagnoses including depression, diabetes, right above-knee amputation, and paraplegia, had an order for Morphine Sulfate ER 60 mg by mouth every 12 hours for osteoarthritis and no order or assessment to self-administer medications. Facility policy required staff to remain with residents until medications were swallowed and prohibited leaving medications at the bedside unless specifically ordered. During observation, surveyors saw a brown pill in a medication cup with water on the resident’s bedside table with no staff present; the resident stated it was his/her medication and then self-administered it. An LPN reported having given the resident morphine earlier and speculated the resident must have spit it out, while a CMT stated the resident’s medications had not yet been given and that medications should not be left in the room. Further observations showed additional failures in controlled substance handling. During a skin assessment, the ADON found a small round white pill under the resident in bed, initially assumed it was morphine, placed it on the bedside table, and later crushed and disposed of it at the medication cart. Upon checking the narcotic box, the ADON determined the pill was Oxycontin, a Schedule II opioid for which the resident had no physician order, and noted that another resident on the unit had a card of Oxycontin in the narcotic box. The resident’s prescribed morphine was described as a small brown pill matching the medication seen at the bedside earlier. The DON and Administrator stated they would not expect controlled medications to be in a resident’s bed or for a resident to have medications not prescribed to him/her, and another ADON stated that nurses should sign out narcotics as they are pulled and ensure residents take medications before leaving the room. Resident #7 was not known to pocket or spit out medications.
Failure to Offer Roommate Option to Leave After Co-Resident’s Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated in a dignified manner after his/her roommate died in their shared room. According to medical record review, Emergency Medical Services (EMS) pronounced the roommate deceased at 1:47 A.M., and the funeral home did not remove the body until 5:09 A.M. During this time, the surviving resident, who was cognitively intact and had diagnoses including quadriplegia, malnutrition, diabetes, and general muscle weakness, remained in the same room. The surviving resident was in the bed farthest from the door, and staff closed the privacy curtain between the beds and likely closed the room door, but did not remove the resident from the room. In an interview, the surviving resident reported that no one came in to ask if he/she wanted to leave the room or if he/she was okay, and stated that he/she did not like the situation and felt very upset and uncomfortable, particularly in light of a recent loss of his/her son. Staff interviews indicated that both an LPN and a CNA understood that standard practice when a resident passes away is to take the roommate out of the room or at least offer the option to leave, especially when family comes to see the deceased resident. The Administrator and DON confirmed they would expect staff to ask the roommate to leave the room after a death and stated it was not dignified to leave the roommate in the room or to have family see the deceased with the roommate still present.
Failure to Complete Dietician-Requested Reweight and Timely Follow-Up of Oncology-Ordered Labs
Penalty
Summary
The facility failed to ensure services met professional standards when staff did not obtain a repeat weight as requested by the registered dietician for a resident with multiple comorbidities, including diabetes, aphasia, dysphagia, dementia, and delusional disorder. The resident’s care plan identified a nutritional problem or potential nutritional problem, with goals to maintain weight within 5–10% of usual weight and consume at least 75% of 2–3 meals daily. The weight summary showed a decline from 192.5 lbs to 187.2 lbs and then to 166.2 lbs over three consecutive monthly weights, with no further weights documented. On a dietician progress note, a “weight warning” was documented with a request for a reweight. The restorative aide/CNA, who was responsible for obtaining and documenting weights, reported that the dietician’s reweight requests were communicated via email from the ADON and acknowledged that the resident was on the reweight list but the reweight could not be found in the record. When the resident was weighed during the survey, the weight was 163.7 lbs, confirming that the requested reweight had not been completed and documented within the expected timeframe. The facility also failed to ensure that requested laboratory tests from an outside oncology provider were completed and followed up on in a timely manner for another resident with diagnoses including liver cancer, generalized muscle weakness, and Alzheimer’s disease. An order for a CBC and CMP was entered and marked complete, and progress notes documented calls to the oncologist’s office indicating that labs had been drawn and were pending. The lab report later showed that the CMP specimen was hemolyzed with a directive to call to reschedule, but there was no documented follow-up or redraw by facility staff. The oncology office social worker reported that after a December appointment, lab orders were sent with the resident and CNA, and also called and faxed to the facility, with instructions for labs to be completed between Christmas and New Year. The resident’s follow-up appointment was cancelled by the facility due to transportation issues, and the ordered labs were not actually completed until later at the oncology office, which had not received any lab results from the facility and was unaware of the hemolyzed specimen.
Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure staff followed its Enhanced Barrier Precautions (EBP) policy and failed to implement EBP for a resident with multiple open areas. The facility’s EBP policy, last reviewed 5/15/24, required the use of gowns and gloves during high-contact resident care activities, including wound care and dressing changes, for residents with wounds and/or indwelling medical devices, and directed that EBP signage be posted and PPE be available in the room. Review of the resident’s medical record showed diagnoses including hemiplegia following a left-sided stroke and high blood pressure. The resident’s care plan identified a pressure ulcer to the sacrum related to immobility and bowel and bladder episodes, with interventions to administer treatments as ordered and follow facility policies for treatment and prevention of skin breakdown, but there was no mention of EBP precautions. Further review of the electronic physician order sheet and January 2026 Treatment Administration Record showed no order for EBP precautions. During observation of wound care, two LPNs prepared to treat the resident’s large open wound to the buttocks. At the treatment cart outside the room, one LPN gathered wound care supplies, entered the room, and placed the items on a disposable pad on the bedside table. Both LPNs washed their hands; one LPN donned gloves and a gown from a shelf on the resident’s door and placed an extra gown on the bed, pointing to the other LPN, who donned gloves but did not put on the gown. Both staff assisted in rolling the resident to the left hip to expose the wound, during which the extra gown fell to the floor. One LPN removed the old dressing, cleansed the wound, changed gloves with hand hygiene in between, and applied the ordered treatment while the other LPN held the resident’s hips to maintain position, remaining gloved but ungowned throughout the high-contact wound care activity. After completing treatment, the gowned LPN removed the gown and gloves, performed hand hygiene, and removed trash from the room, while the ungowned LPN repositioned the resident and exited the room. In a subsequent interview, the DON and Administrator stated they would expect staff to follow the policy and for both nurses to wear appropriate PPE for EBP.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information (PHI) when a staff member provided an after-visit summary containing personal and medical details of one resident to the family member of a different resident. The summary included the resident's full name, date of birth, medical record number, referrals for further testing, and results of a recent x-ray. The family member who received the document reported the error to the staff member, but the staff member responded indifferently, stating they did not care and did not want the paperwork back, allowing the family member to keep the document. The incident was confirmed through interviews, observation, and record review. The family member retained the after-visit summary and provided it to the surveyor as evidence. The facility's posted resident rights statement included confidentiality, and management acknowledged that only residents, their guardians, or POAs should have access to such records. The administrator stated that, in such cases, staff are expected to retrieve the documents and notify management, but this did not occur in this instance.
Failure to Maintain Homelike Environment and Adequate Dining Service
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. One resident with moderate cognitive impairment, a history of stroke, aphasia, hemiplegia, and schizophrenia was found in a room that was not swept daily, with trash on the floor and a bedside table with screws protruding from the surface. The condition persisted over two days, and the housekeeping supervisor acknowledged that the screws were not homelike and that the table was an older, unused piece of furniture. Housekeeping staff were expected to clean rooms daily, but staffing shortages were noted. Another resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and hemiplegia, had two dirty plates with dried food left on the air conditioning unit in their room for at least two days. The resident reported that the plates were from previous meals, and the housekeeping supervisor stated that staff should remove such items or notify nursing. The supervisor also noted that trash should be removed in the morning and rooms checked again before staff leave, but acknowledged recent short staffing. Additionally, the facility did not provide a sufficient number of regular dining plates, resulting in residents being served meals on Styrofoam plates wrapped in plastic. Multiple residents reported dissatisfaction with the use of Styrofoam, stating that it made food cold and unappetizing, and that plates were often removed before they finished eating so they could be washed for the next meal. Observations confirmed that regular plates were in short supply, with staff switching to Styrofoam when plates ran out. The dietary manager and staff confirmed the ongoing shortage, and the administrator provided documentation of a recent order for a small number of plates, but could not locate records of previous orders.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain a complete and accurate record of receipt and disposition of all controlled drugs for a resident, resulting in the loss of a narcotic count sheet for one card of 30 Oxycodone 20 mg tablets. The pharmacy delivered a 30-day supply of 120 tablets, divided into four cards of 30 tablets each, and records confirmed receipt by the facility. While three of the four controlled substance sheets were available and reconciled, one sheet was missing, leaving no documentation or reconciliation for the administration of 30 tablets. The medication administration record (MAR) showed that doses were given and documented, but the corresponding narcotic count sheet for one card could not be located. Interviews with staff revealed that narcotic medications are signed in upon delivery and are supposed to be accounted for on controlled substance sheets, with reconciliation at the beginning and end of each shift. The LPN interviewed did not recall any discrepancies or resident complaints regarding pain medication. The DON confirmed the missing narcotic sheet and stated that all sheets should be accounted for, with staff expected to sign out and document administration of controlled medications. The administrator also acknowledged the expectation for accurate reconciliation of narcotics.
Failure to Use Mechanical Lift for Dependent Resident Transfer
Penalty
Summary
Facility staff failed to follow the established policy and physician orders regarding safe transfer methods for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, hemiparesis, a history of falls, unsteadiness, dementia, and legal blindness, was care planned and ordered to be transferred using a mechanical Hoyer lift with an appropriate sling for all transfers. Despite these orders and the facility's Total Lift Transfer policy, two CNAs transferred the resident from a wheelchair to a bed using a gait belt instead of the required mechanical lift. During the transfer, the wheelchair was not locked, and the resident was lifted by the gait belt while their feet did not touch the floor, and they did not stand up as instructed. The resident exhibited discomfort, moaning, and yelling during the transfer. Interviews with staff, including CNAs, an LPN, and the interim DON, confirmed that staff were expected to follow transfer orders and care plans, and that the resident should have been transferred using the Hoyer lift at all times. The CNAs involved did not adhere to these expectations, resulting in a transfer that was not in accordance with the resident's care plan or physician orders. The Administrator and Regional Director of Operation also stated that staff were expected to follow appropriate transfer methods as ordered and care planned.
Failure to Verify Nursing Licensure for LPN
Penalty
Summary
The facility failed to ensure that nursing staff were properly licensed to practice in the state of Missouri. An LPN, who had obtained a nursing license in Illinois, was employed and worked as a GPN and later as an LPN in the facility without holding a Missouri nursing license. Review of records showed that the LPN had completed a practical nursing program and began working as a GPN, but after passing the licensure examination, continued to work as an LPN without Missouri licensure. The LPN provided direct care, including medication administration, wound care, and care for residents with tracheostomies and tube feedings, often without direct supervision or pairing with an experienced nurse. Interviews with facility staff revealed that there was an expectation for GPNs to work under the oversight of a licensed nurse and for HR to verify and track licensure status, including the 90-day limit for GPNs to obtain licensure. However, HR did not verify that the LPN was licensed in Missouri, and neither the new DON nor the Administrator were aware of the situation until it was brought to their attention by the state surveyor. The LPN resigned after the issue was discovered. The failure to verify and ensure proper licensure had the potential to affect all residents in the facility.
Failure to Investigate and Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy when two residents were involved in a physical altercation. Both residents had documented histories of potential aggression, with care plans indicating the need for interventions and monitoring. Following the incident, one resident was observed to have a mark under the eye, and a family member reported the resident had a black eye as a result of being punched. Staff interviews confirmed that a physical altercation occurred, with one resident grabbing and hitting the other, leading both to fall to the floor. Immediate assistance was called, and both residents were assessed by nursing staff, with recommendations for hospital evaluation. Despite the clear evidence of a resident-to-resident altercation resulting in injury, the facility did not initiate a thorough investigation as required by its Abuse Prevention Policy. There was no documentation of an investigation, and key staff members, including the Activity Director and Certified Nurse Aide who witnessed or responded to the incident, were not asked to provide written statements. The incident was not reported to the State Survey Agency or other required officials, and there was no documentation of the event in the residents' nurse's notes beyond the initial hospital referral. Interviews with facility leadership, including the Regional Director of Nursing and the Administrator, revealed that the incident was not reported or investigated according to policy. The Administrator acknowledged responsibility for ensuring the policy is followed and for reporting abuse and neglect allegations but was unable to explain why the required actions were not taken. The lack of investigation and reporting represents a failure to protect residents from abuse and to comply with regulatory requirements.
Failure to Notify Physician and Dietitian of Significant Weight Loss
Penalty
Summary
The facility failed to follow its own policies regarding the monitoring and management of significant weight loss for a resident. The resident, who had diagnoses including high blood pressure, diabetes, asthma, dehydration, severe protein-calorie malnutrition, and gastro-esophageal reflux disease, experienced an 11.5-pound weight loss over 56 days. Facility policy required that significant, insidious, or unintentional weight loss be reported to the Registered Dietitian (RD) and the physician, with subsequent assessment and intervention. However, there was no documentation that the RD or physician were notified of the resident's weight loss or of the hospital's recommendation for nutritional supplements upon the resident's return from hospitalization. The resident's care plan included monitoring for signs and symptoms of malnutrition and significant weight loss, with specific thresholds for reporting. Despite this, records showed gaps in meal consumption documentation and a lack of follow-up on the resident's nutritional status after multiple hospitalizations for conditions including hypoglycemia and diabetic ketoacidosis. The resident's weight continued to decline, and the resident reported concerns about weight loss and not having seen the RD for assistance. Interviews with staff, including the RD and physician, confirmed that they were not made aware of the resident's weight loss or the need for intervention. Facility staff interviews revealed that procedures for reviewing hospital records and implementing recommendations were not consistently followed. The RD stated that notification of significant weight loss was expected but did not occur. The physician also indicated that the facility should have identified the weight loss and involved the RD. The lack of communication and failure to implement required assessments and interventions directly contributed to the deficiency in providing adequate nutrition and monitoring for the resident.
Failure to Notify Physicians and Document Blood Glucose Management
Penalty
Summary
The facility failed to ensure that staff consistently notified physicians when residents' blood glucose levels exceeded the parameters ordered by the physician or those outlined in facility policy. In several instances, staff did not document blood glucose levels on the Medication Administration Record (MAR) or provide explanations when using codes such as NA (not administered), NI (no insulin required), or HD (hold) on the MAR. This deficiency was identified among four residents sampled from a group of forty-eight who required routine blood glucose monitoring. For one resident with a history of diabetes, high blood pressure, renal disease, and stroke, there were multiple occasions where blood glucose readings were either critically low or high, but there was no documentation that the physician was notified as required by the physician's orders. Additionally, there were instances where insulin was not administered as ordered, and no explanation or blood glucose level was documented. Similar issues were observed with other residents, including missing documentation for blood glucose levels, lack of physician notification when levels were outside of ordered parameters, and unexplained use of MAR codes indicating insulin was not given or held. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to notify physicians when blood glucose levels were outside of specified parameters and to document these notifications and any reasons for not administering insulin in the progress notes. Despite inservices and reminders, the problem persisted, with staff failing to follow protocols for physician notification and documentation, as evidenced by the review of records and staff interviews.
Failure to Provide Oral Care Supplies and Assistance
Penalty
Summary
The facility failed to ensure that residents had access to oral care supplies, such as toothbrushes, toothpaste, and mouthwash, and did not consistently provide oral care assistance as required by their care plans. Observations and interviews revealed that several residents did not have these supplies in their rooms and reported that staff did not offer to assist with oral hygiene. Specifically, three residents stated they had not received oral care supplies since admission and that staff had not offered to help with oral care, despite their expressed desire for assistance. Review of the residents' medical records and care plans showed that some required setup or clean-up assistance, while others needed substantial or maximal assistance with oral hygiene due to physical or cognitive limitations. For example, one resident with muscle weakness and chronic kidney disease required setup assistance, while another with end-stage renal disease and diabetes needed substantial help. Despite these documented needs, staff interviews confirmed that oral care was not consistently offered, and supplies were not available in the residents' rooms. Staff members, including CNAs, a Certified Medication Technician, and an LPN, acknowledged during interviews that oral care should be part of the daily routine for all residents. The DON also confirmed the expectation that each resident should have oral care supplies and receive assistance as needed. However, direct observations and resident interviews demonstrated that these expectations were not being met, resulting in a deficiency related to the provision of oral hygiene care.
Failure to Provide Prescribed Restorative Services Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative services as prescribed for residents referred to the restorative program by the therapy department. Nineteen residents were identified as receiving restorative services, and four of these had specific restorative exercise plans developed by therapy. However, these four residents were not receiving the services according to their restorative therapy plans. Observations and interviews revealed that residents were not receiving the required range of motion (ROM) exercises and other restorative interventions as ordered, with some residents reporting that they had not received services for weeks or could not recall the last time they received them. Documentation showed that these residents only received restorative therapy twice in the previous ten days, despite plans calling for three sessions per week. Staff interviews indicated that the restorative aide was frequently reassigned to other duties, resulting in restorative services not being delivered consistently. The restorative aide confirmed being pulled to the floor almost daily, and the Director of Nursing acknowledged that the restorative program was not functioning as intended. The physical therapist was aware that restorative services were not being provided as ordered due to staffing issues. Review of staffing sheets confirmed that the restorative aide was reassigned to other duties on seven out of twelve days reviewed. Residents affected by this deficiency included individuals with significant mobility limitations, such as incomplete quadriplegia, muscle weakness, and impaired range of motion. These residents required assistance with activities of daily living and had care plans specifying the need for restorative interventions to maintain or improve their functional status. Despite these documented needs and therapy recommendations, the facility did not ensure that restorative services were delivered as planned.
Failure to Provide Timely Discharge Planning and Capacity Assessment
Penalty
Summary
The facility failed to provide necessary social services by not promptly developing a discharge plan or seeking professional medical or psychiatric evaluations to determine if a resident, who was homeless and their own legal representative, had the right to discharge to the community, discharge against medical advice (AMA), or if legal guardianship should be pursued. The resident, with diagnoses including bipolar disorder and anxiety, was admitted from a hospital and placed on a locked unit after expressing a desire to leave and attempting to do so. Despite repeated expressions of wanting to leave, confusion, and fluctuating cognitive status, there was no timely assessment or documentation regarding the resident's capacity to make discharge decisions or the appropriateness of their placement on a locked unit. The social services documentation was inconsistent and incomplete. Discharge planning reviews and care plans lacked critical information, such as the resident's living situation, support network, and overall summary of potential for discharge. There was no evidence that referrals to local contact agencies or community resources were made in a timely manner, and the care plan did not address the resident's placement on the locked unit or discharge planning. The psychiatric nurse practitioner was not asked to evaluate the resident's decision-making capacity until months after admission, despite ongoing concerns about the resident's ability to safely live independently and repeated requests to leave the facility. Interviews with staff revealed a lack of clarity regarding policies for seeking legal guardianship or managing residents on locked units. The social services department experienced turnover, further disrupting continuity of care and discharge planning. The resident continued to express a desire to leave, called 911 alleging being held against their will, and was found to have diminished capacity only after a delayed psychiatric evaluation. Throughout this period, the facility did not adequately coordinate or document efforts to address the resident's psychosocial needs, discharge planning, or legal status, resulting in a failure to provide necessary social services as required.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Accommodate Resident Bathroom Access Due to Locked Adjoining Bathroom
Penalty
Summary
The facility failed to provide reasonable accommodations for the individual needs and preferences of two residents by denying them access to their adjoining bathroom. Staff removed the doorknobs from the bathroom doors, locking the bathroom and requiring the residents to request staff assistance to access the main bathroom in the hallway. This action was taken despite a lack of clear documentation or evidence that either resident was responsible for clogging the toilets, and staff interviews revealed uncertainty about which resident, if any, had caused the issue. Both residents were observed to have their bathroom doors locked and inaccessible without maintenance assistance. One resident had moderate cognitive impairment, was wheelchair-bound, and was dependent on staff for toileting and transfers. The resident's care plan did not document any history of clogging toilets, and there was no evidence in progress notes of such behavior. The resident reported having to use a urinal or hold their bowels until staff could assist them to the main bathroom, sometimes resulting in incontinence. Staff interviews confirmed the resident did not have access to the bathroom in their room and did not know the code to the main bathroom, requiring staff intervention each time toileting was needed. The second resident also had moderate cognitive impairment and required partial to moderate assistance with toileting. Their care plan mentioned a history of behavior problems and clogging the toilet with foreign objects, but there was no documentation of specific incidents. Observations showed the resident's bathroom was also locked, and the resident resorted to urinating in a trash can in their room. Staff interviews indicated a lack of knowledge about the reason for the bathroom's inaccessibility and no awareness of recent clogging incidents. The administrator confirmed that the bathroom was locked due to uncertainty about which resident was responsible for previous clogs and flooding, and both residents were instead provided with bedside commodes and access to the main bathroom only with staff assistance.
Failure to Maintain Sanitary and Homelike Environment for Two Residents
Penalty
Summary
Staff failed to maintain a safe, clean, and homelike environment for two residents who shared an adjoining bathroom. Observations revealed that the bathroom doorknobs were missing and inaccessible to the residents, and the bathroom itself was left in unsanitary condition, with soiled towels piled on the floor, brown smears above the tile, and a solid dark substance in the toilet bowl. The wall across from the toilet was covered with brown cardboard instead of tile. Maintenance staff reported that the doorknobs were removed due to residents' behaviors of clogging the toilet and smearing feces, and that the bathroom was locked as a result. One resident had moderate cognitive impairment, was dependent on staff for toileting and transfers, and had a history of urinary and occasional bowel incontinence, as well as diagnoses including hypertension and Alzheimer's disease. The other resident also had moderate cognitive impairment, required partial to moderate assistance with toileting, and had diagnoses including heart failure, pulmonary edema, diabetes, and hypertension. Observations in the second resident's room showed a trash can with a plastic liner containing yellow liquid, which staff confirmed was urine, and reported that the resident frequently urinated in the trash can and defecated in inappropriate places in the room. Housekeeping staff stated that they cleaned the resident's room daily, removed soiled trash liners, and replaced them, but acknowledged that the resident regularly urinated in the trash can. The facility's policy required maintaining a sanitary and comfortable environment, including prompt cleaning and reporting of environmental concerns. The administrator was aware of the unsanitary bathroom conditions and stated that the staff responsible was no longer employed, but expected all staff to follow cleaning policies.
Failure to Provide Appropriate Diet and Supervision for Resident at Risk of Aspiration
Penalty
Summary
The facility failed to ensure that a resident, who was assessed to be at risk for aspiration, was served meals in accordance with physician's orders. The resident, who had a history of transient ischemic attack and severe cognitive impairment, was supposed to receive a pureed meat texture diet and nectar-thick liquids following a recent hospitalization for aspiration pneumonia. However, observations revealed that the resident was given un-thickened liquids and mechanical-soft sausage instead of the prescribed diet, which posed a risk of choking and further aspiration. The resident's care plan did not adequately address the risk of aspiration or specify the level of assistance and supervision required during meals. Despite the resident's known behavior of chewing on non-food items, such as linens and napkins, staff failed to provide the necessary supervision. On one occasion, the resident was observed chewing on a milk-soaked napkin without staff intervention, highlighting a lack of awareness and monitoring by the facility staff. Interviews with facility staff, including LPNs, CNAs, and the Dietary Manager, revealed a lack of communication and understanding of the resident's dietary needs and supervision requirements. The dietary slips used during meal service were outdated, and staff were not informed of the updated dietary orders. This lack of coordination and oversight contributed to the resident receiving inappropriate meals, which could have led to further health complications.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for eight of 33 sampled residents, as evidenced by unclean conditions in resident rooms and common areas. Observations revealed that Resident #8's room had a gray film of grime on the floor and dried red liquid stains, with fecal material splattered inside the toilet bowl. Despite the resident's complaints, the room remained unclean over several days. Similarly, Resident #119's room had dirty floors with trash and food debris, dirty bedding with a brown substance, and a strong fecal odor, which persisted over multiple observations. Resident #38's room was noted to have dust accumulation on the air conditioning unit and trash and food debris around the bed. Resident #62's room had a dresser door hanging off and food and trash debris on the floor. Resident #15's room had dust, crumbs, and dried red splatters on the floor and bed frame, with the resident expressing dissatisfaction with the cleanliness. Housekeeping staff expressed uncertainty about cleaning around oxygen equipment, indicating a lack of clear guidance. Additionally, soap dispensers in the rooms of Residents #20 and #140 were found empty over several days, despite residents' complaints. Resident #105's tube feeding equipment was observed with layers of dry, flaky matter, and the 400 hallway dining room had sticky floors with food debris over several days. Interviews with housekeeping staff and supervisors revealed expectations for daily cleaning and maintenance, but these were not met, leading to the deficiencies observed.
Expired Medications Found in Facility Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During observations, surveyors found expired medications and biologicals in two of the facility's medication rooms and two of the three medication administration carts. Specifically, expired ESwab Liquid collection kits, CareAll Tetrahydrolozine HCl Eye Drops, ProCure Allergy Relief tablets, Assure Dose Accucheck Control Solution, and GeriCare Zinc Sulfate tablets were identified. These findings indicate a lapse in the facility's adherence to its own Medication Storage policy, which mandates the removal and destruction of expired medications. Interviews with facility staff revealed a lack of clear responsibility for auditing medication storage areas for expired items. Certified Medication Technicians and floor nurses were expected to check for expired medications weekly, but no single staff member was designated to ensure compliance. The night nurses were tasked with auditing medication carts weekly, while the Assistant Directors of Nursing were supposed to audit medication rooms daily. However, the presence of expired medications suggests that these procedures were not effectively implemented or monitored, leading to the observed deficiencies.
Facility Fails to Maintain Kitchen Cleanliness Standards
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the kitchen, as observed during multiple inspections. On several occasions, the walk-in refrigerator and freezer were found with food debris and trash on the floors. The kitchen floors, particularly around the dishwashing sinks and preparation stations, had accumulated dark matter, dead bugs, and spilled liquids. Additionally, the ceiling and vents above the main food preparation station were covered in dust and cobwebs, while the bulk bin lids had food debris and white powder buildup. The deep fryer and oven were observed with sticky liquid substances and food particles, indicating a lack of regular cleaning. Interviews with staff revealed discrepancies in cleaning expectations and practices. The kitchen cleaning checklists, which were undated, outlined daily and weekly cleaning tasks, but these were not being adhered to. Staff members, including the Dietary Supervisor and the Administrator, expressed expectations for cleanliness that were not being met. The Dietary Supervisor mentioned that maintenance was responsible for cleaning the ceilings weekly, and that the deep fryer and oven should be cleaned twice a week, with oil changes occurring weekly. However, observations indicated that these tasks were not being performed as required, leading to the unsanitary conditions documented in the report.
Deficiencies in ADL Care and Hygiene Observed
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for four residents, leading to deficiencies in personal hygiene and grooming. Resident #22, who has severe cognitive impairment and requires extensive assistance with ADLs, was observed with unwanted facial hair despite expressing a desire to be free from it. This indicates a failure in grooming assistance as outlined in the resident's care plan. Resident #32, also with severe cognitive impairment, was not care planned for ADL care and was observed with greasy hair, dirty hands, and food debris on clothing. This lack of planning and oversight resulted in the resident not receiving necessary hygiene care. Similarly, Resident #62, with moderately impaired cognition, was observed with oily hair, long nails with dark matter underneath, and wearing the same clothing over several days. The resident reported not having other clothing, and staff confirmed missed showers due to behavioral issues in the hallway. Resident #71, with severe cognitive impairment, was not care planned for ADL or hygiene care and was observed wearing the same clothing over multiple days. The facility's staff, including a Certified Medication Technician and an LPN, acknowledged expectations for residents to have clean clothing, hands, and hair, and for care plans to reflect ADL assistance needs. However, these expectations were not met, as evidenced by the observations and interviews conducted during the survey.
Failure to Accommodate Resident's Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with significant communication and mobility impairments. The resident, who had a history of stroke, hemiplegia, and aphasia, was observed with their call light out of reach, pinned to a privacy curtain on their non-functional side. Despite the resident's attempts to communicate their inability to reach the call light, staff did not rectify the situation, leaving the resident without a means to call for assistance. Additionally, the resident expressed a desire to return to bed, which was not honored by the staff. The resident was observed in a geri-chair at the nurse's station and later in their room, repeatedly stating their wish to lie down. Staff, including CNAs, indicated that the resident needed to remain up to prevent pressure ulcers and due to staffing requirements for using a Hoyer lift. Despite the resident's clear communication of their preference, the staff did not assist the resident back to bed until after lunch, contrary to the resident's wishes. Interviews with staff, including a CNA, RN, and the Director of Nurses, revealed a lack of adherence to the resident's rights and care plan. The staff acknowledged the resident's ability to make their needs known and the necessity of having the call light within reach. However, the care plan did not adequately address the resident's communication difficulties or mobility limitations, nor did it reflect the resident's preferences for being in bed. The facility's failure to ensure the resident's call light was accessible and to honor their request to return to bed demonstrated a disregard for the resident's rights and preferences.
Failure to Complete Timely Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment within 14 days for a resident who was admitted to hospice care. The resident, who had a primary diagnosis of cerebrovascular disease, was admitted to hospice on May 15, 2024. However, the facility did not complete the required significant change Minimum Data Set (MDS) assessment within the mandated timeframe. The facility's policy requires that a significant change MDS be completed when a resident enters hospice, but this was not done for the resident in question. The MDS Coordinator, responsible for completing all MDS assessments, acknowledged that the significant change MDS was not completed. She mentioned that she is informed of changes in residents' status during department head risk meetings, but the resident's hospice admission was not listed on the electronic physician order sheet, which may have led to the oversight. The Administrator confirmed that the MDS Coordinator is expected to ensure timely completion of significant change MDS assessments, indicating a lapse in the facility's adherence to its own policies and federal requirements.
Inaccurate MDS Assessments for Hospice and Fall Incidents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. One resident, who was admitted to hospice with a primary diagnosis of cerebrovascular disease and a life expectancy of less than six months, was not accurately reflected in the MDS. The MDS did not indicate the resident's hospice status or their life expectancy, which was a critical oversight. This discrepancy was attributed to the hospice admission not being listed on the resident's electronic physician order sheet, which the MDS Coordinator missed. Another resident, who had a history of significant medical conditions including an amputation, hemiplegia, and muscle weakness, experienced a fall during the assessment review period. However, this fall was not documented in the resident's quarterly MDS. The MDS Coordinator acknowledged the oversight after reviewing the incident note. The facility's policy requires that such incidents be accurately recorded in the MDS, but the coordinator, who was solely responsible for completing all MDS assessments, failed to include this information.
Failure to Transcribe Physician Orders Correctly and Unauthorized Medication Crushing
Penalty
Summary
The facility failed to ensure that physician orders were correctly transcribed to the Medication Administration Record (MAR) for two residents, leading to discrepancies in the administration of tube feedings. Resident #105, who has aphasia, stroke, and seizure disorder, was receiving parenteral tube feeding. The physician's order specified that the tube feeding should be administered from 6:00 A.M. to 12:00 A.M., but the MAR incorrectly listed the administration times as 7:00 A.M. and 7:00 P.M., omitting the specific start and stop times. Similarly, Resident #49, with a seizure disorder and traumatic brain injury, had a physician's order for tube feeding from 6:00 A.M. to 10:00 P.M., but the MAR did not reflect the time to stop the feeding at 10:00 P.M. Additionally, the facility administered crushed medications to Resident #72 without a physician's order. This resident, diagnosed with dysphagia, Parkinsonism, dementia, and Alzheimer's disease, was observed receiving crushed medications mixed with applesauce, despite the absence of an order to do so. The Certified Medication Tech (CMT) responsible for administering the medications relied on an unofficial list from the narcotic binder, which was not part of the facility's policy or orders, instead of the MAR or physician orders. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that there was an expectation for physician orders to be accurately transcribed to the MAR, including specific times for tube feedings and orders for crushing medications. The ADON acknowledged that the orders had not been checked recently due to being off work, and the DON confirmed that the unofficial list used by the CMT was not recognized as part of the facility's procedures. The failure to adhere to professional standards of practice in transcribing and implementing physician orders led to these deficiencies.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to adhere to physician orders and proper infection control techniques for two residents requiring oxygen therapy. Resident #15, who has a history of COPD and other respiratory issues, was observed to have increased the oxygen flow rate to 5 liters per minute without staff awareness, contrary to the physician's order of 3 liters per minute. The resident's pulse oximetry results were not documented, and the oxygen tubing was not dated as required. Interviews with nursing staff revealed a lack of awareness regarding the resident's self-adjustment of oxygen levels and inconsistencies in documenting pulse oximetry readings. Resident #315, also diagnosed with COPD and chronic respiratory failure, was observed to have their nasal cannula frequently on the floor, with the oxygen concentrator left running when not in use. The resident reported difficulty retrieving the nasal cannula, and staff interviews indicated a lack of clarity regarding the resident's oxygen orders. The facility's expectations for maintaining infection control by keeping the nasal cannula off the floor and turning off the concentrator when not in use were not met. Interviews with the facility's administration and nursing leadership highlighted discrepancies in the documentation and implementation of physician orders. The Assistant Director of Nursing acknowledged that the orders were entered incorrectly into the system, leading to improper documentation and execution of care. The facility's policies on oxygen administration and storage were not followed, resulting in deficiencies in the care provided to the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) for residents with specific medical conditions, as recommended by the CDC and required by CMS. The deficiency was observed in three residents who had central lines, gastrostomy tubes, or wounds requiring treatment. Despite the presence of EBP signage and PPE caddies in the residents' rooms, staff did not consistently wear gowns during high-contact care activities, such as changing incontinence briefs and providing perineal care. Resident #97, who was cognitively intact and received dialysis, had a dialysis catheter and a recent leg amputation. Although an EBP sign was posted, staff did not wear gowns while providing care, including during the use of a Hoyer lift. Similarly, Resident #105, who was rarely understood and received parenteral tube feeding, had an EBP sign and PPE available, but staff did not wear gowns during care activities. Resident #265, who had a g-tube and was admitted with conditions such as diabetes and hemiplegia, also had an EBP sign, yet staff failed to wear gowns during care. Interviews with facility staff, including a Registered Nurse, a CNA, and the Assistant Director of Nursing, revealed a lack of consistent understanding and implementation of EBP protocols. Staff acknowledged the requirement for gown and glove use during high-contact care for residents with MDROs, dialysis catheters, and other medical devices, but this was not consistently practiced. The facility's administration expected EBP to be included in care plans and physician orders, but this was not always the case, contributing to the deficiency.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple observations and interviews. One resident, who required staff assistance with mobility and personal care, was left with their buttocks exposed while being transported through common areas of the facility. Additionally, the resident was left uncovered in bed with their genitals exposed, visible from the hallway. Staff also failed to empty the resident's urinals, leaving them full and in the resident's line of sight while they ate lunch. Interviews with staff confirmed that these actions were inappropriate and did not align with the facility's policies on resident dignity and privacy. Another incident involved a staff member making a video call on their personal cell phone in a common area, with a resident visible in the background. This action was in violation of the facility's phone policy, which restricts phone use to break rooms or areas away from resident care, and posed a potential HIPAA violation. Interviews with other staff members and the facility's administration confirmed that such actions were not appropriate and breached resident privacy. The facility's policies on resident rights, last reviewed in April 2023, emphasize treating residents with kindness, respect, and dignity, and ensuring privacy and confidentiality. However, the observed incidents indicate a failure to adhere to these policies, resulting in a lack of respect for resident dignity and privacy. The facility's administration acknowledged these deficiencies and the need for staff to follow proper procedures to maintain resident dignity and privacy.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were appropriately assessed for self-administration of medications, obtain necessary physician orders, and adequately supervise residents during medication administration. Specifically, two residents were involved in this deficiency. Resident #20, who has diagnoses including schizophrenia, dysphagia, and myasthenia gravis, was found with medications and an inhaler on their bedside table without a physician's order for self-administration. The resident's cognitive status was noted to fluctuate, and there was no recent assessment to determine their ability to self-administer medications safely. Resident #214, diagnosed with asthma, shortness of breath, obstructive sleep apnea, and heart failure, was also found with inhalers on their bedside table. Although an assessment indicated the resident was capable of self-administering inhalers, there were no physician orders to support this practice. The baseline care plan did not specify which medications the resident was authorized to self-administer, leading to a lack of clarity and potential safety concerns. Interviews with facility staff, including a CMT, LPN, RN, and the Director of Nurses, revealed inconsistencies in the understanding and implementation of the facility's policies regarding self-administration of medications. Staff acknowledged that medications should not be left at the bedside without proper assessment and physician orders, and residents should be observed during medication administration to ensure safety. The facility's failure to adhere to these protocols resulted in the identified deficiencies.
Failure to Maintain Accurate Resident Property Records
Penalty
Summary
The facility failed to maintain accurate records of residents' personal possessions for four residents, as observed through interviews and record reviews. Resident #97's inventory sheet, dated 8/28/24, did not reflect the personal items observed in the room, such as clothing and hygiene items. Resident #38's inventory sheet was incomplete and unsigned, and the resident reported receiving clothing from the facility's lost and found, which was not labeled with their name. Resident #15's inventory sheet was undated and unsigned, and Resident #265's sheet was not signed by staff, with missing items reported by a family member. Interviews with staff revealed inconsistencies in the process of documenting and maintaining personal property inventories. A CNA mentioned using a blank sheet of paper for inventory, while an LPN stated that forms were available at the nurses' desk. The Concierge was responsible for updating inventory lists, but there was confusion about the process when new items were brought in. The Administrator and DON expected staff to complete and update inventory sheets, ensuring they were signed and dated, but this was not consistently done, leading to discrepancies in residents' personal property records.
Failure to Manage Resident's Financial Affairs and Communicate Billing Issues
Penalty
Summary
The facility failed to obtain written authorization to use the personal funds of a resident who was discharged in January 2024 with a credit of $772.00. The resident was later charged $875.00 in October 2024 after an updated bill was received from the resident's co-insurance, resulting in a balance owed of $103.00. The facility did not notify the resident or their responsible party about the additional charges before deducting the amount, which led to the deficiency. The facility's Admission Agreement stated that payments are due by the fifth of the month and that any overpayments would be withheld until all third-party payments were received. Despite this, the Business Office Manager (BOM) sent a refund request in March 2024, which was acknowledged in April 2024, but the refund was not processed in a timely manner. The Regional Business Manager indicated that refunds should be processed within five to thirty days, but the resident's refund was delayed due to waiting for confirmation of out-of-pocket expenses. Interviews with the BOM and the Regional Business Manager revealed a lack of communication with the resident and their family regarding the outstanding balance and the delay in processing the refund. The BOM mentioned that the resident's daughter inquired about the funds, and the Administrator expected timely refunds and communication with the resident's family about any billing issues. The deficiency was identified due to the facility's failure to manage the resident's financial affairs appropriately and communicate effectively with the resident and their family.
Delayed Refund of Resident Funds
Penalty
Summary
The facility failed to refund resident funds within 30 days of discharge for a resident who was discharged in January 2024 with a credit balance of $772.00. Despite attempts to notify the corporate office to issue the refund, the facility did not process the refund in a timely manner. The resident was a private pay from January 6, 2024, until January 16, 2024, and had overpaid for room and board charges. The Business Office Manager (BOM) sent a refund request to the corporate office on March 27, 2024, which was acknowledged on April 1, 2024, but the refund was not issued. Interviews with the BOM and the Regional Business Manager revealed that the refund process was delayed due to waiting for confirmation of any out-of-pocket expenses owed to the facility and ensuring that all third-party payments were received. The Regional Business Manager stated that a refund should be processed within five to thirty days, but could not explain the delay in this case. The BOM mentioned that managed care and Medicare charges take longer to process, which contributed to the delay in submitting the refund request. The Administrator expected refunds to be returned timely, but the facility's process did not meet this expectation.
Failure to Reactivate Medication Orders Post-Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when the resident's medication and treatment orders were not reentered into the electronic medical record (EMR) until two days after the resident was readmitted from a hospital stay. The resident, who had a history of mild cognitive impairment, schizophrenia, anxiety, high blood pressure, and chronic obstructive pulmonary disease (COPD), returned to the facility on 9/24/24, but the orders were not entered into the EMR until 9/26/24. This delay resulted in the resident not receiving their prescribed medications and treatments during this period. Upon the resident's return, the nurse completed an assessment and contacted the physician for order verification. However, the nurse failed to activate the orders in the EMR, which meant that the medications and treatments were not visible on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Consequently, the Certified Medication Technician (CMT) or nurse could not administer the medications or treatments as there were no active orders to sign off on. The Director of Nursing (DON) and Administrator acknowledged that the orders should have been verified and activated within 24 hours of the resident's readmission. Interviews with facility staff revealed that the nurse responsible for the readmission had asked another nurse to verify the admission process, but the verification was not completed. The DON later discovered that 42 orders were queued but not activated, and some CMTs reported administering medications based on previous orders, although there was no documentation to confirm this. The physician was informed of the situation and confirmed that the resident did not experience any adverse effects from the missed medications.
Failure to Follow G-Tube Feeding Orders
Penalty
Summary
Facility staff failed to provide appropriate care and services to a resident with a gastrostomy tube (g-tube) by not ensuring the g-tube machine infused the correct amount of feeding formula and by not turning off the g-tube machine at the prescribed time. The resident, who had severe cognitive impairment and multiple diagnoses including cancer, kidney failure, and malnutrition, was observed to have the g-tube infusing at 80 ml/hr instead of the ordered 70 ml/hr on two consecutive days. Additionally, the g-tube was not turned off at 8:00 A.M. as ordered, with the Licensed Practical Nurse (LPN) acknowledging the delay and the incorrect infusion rate. The resident's care plan required continuous nocturnal tube feeding with specific goals to maintain adequate nutritional and hydration status. However, observations showed discrepancies in the infusion rate and timing, with the LPN initially unaware of the correct settings. The facility's Administrator and Director of Nursing confirmed that staff are expected to follow physician's orders, and the nurse is responsible for ensuring the g-tube machine is set correctly. These failures were observed during a survey with a sample size of 14 and a census of 166.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide protective oversight for a resident identified as at risk for elopement. The resident, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia and was assessed to have moderate cognitive impairment. Despite a known history of elopement, the staff failed to visibly confirm the resident's whereabouts during routine rounds. As a result, the resident left the building without staff knowledge and was missing for approximately four hours before staff realized the absence. The resident was found 12 hours later, approximately two miles away from the facility, having crossed a busy intersection. The facility's investigation revealed that the resident likely exited through a tampered window in the dining room, as evidenced by removed retaining screws and a torn screen. Staff interviews indicated that the resident was last seen in the dining room and later assumed to be in bed, but upon closer inspection, it was discovered that the resident was not present, leading to the initiation of a Code Gray. The facility's policies and procedures, including the Missing Resident/Elopement policy, were not effectively followed, as staff did not perform visual checks during rounds. The resident's care plan indicated a risk for elopement, yet the staff did not adequately monitor the resident's location. Interviews with staff members revealed a lack of awareness regarding the resident's exit-seeking behavior and the potential for windows to be fully opened, contributing to the oversight that allowed the resident to elope.
Removal Plan
- Educated all nursing staff on visual checks during rounds
- Educated all staff on the facility's elopement policy and procedures
- Completed an audit of all residents at risk for elopement and updated care plans accordingly
- Performed an elopement drill
- Audited all windows and alarmed doors
Failure to Administer Prescribed Cancer Medication
Penalty
Summary
The facility failed to administer a prescribed cancer medication, Capecitabine, to a resident with colon cancer. The resident had a history of moderate cognitive impairment, anemia, congestive heart failure, high blood pressure, dementia, and depression. The resident returned from a doctor's appointment with a new order for Capecitabine, but the medication was not documented or administered as ordered in December 2023 and February 2024. The resident's medical records lacked documentation of the medication orders and the resident's appointments. Interviews with facility staff revealed a breakdown in the process of transcribing and auditing medication orders. LPN A stated that new orders were given to the ADON, but was unaware of the subsequent steps. ADON B admitted to being behind in updating the resident's medical records. The DON explained that the Charge Nurse should transcribe orders and ensure communication with the responsible party, but this was not documented. The Pharmacy Representative confirmed the absence of orders for the medication during the specified periods. The resident's oncologist was unaware of the missed medication administrations and emphasized the importance of the medication in preventing cancer recurrence. The resident's CEA levels, a cancer marker, increased significantly over time, indicating a potential issue with cancer management. The facility's failure to administer the medication as prescribed and document the resident's medical appointments and orders contributed to the deficiency.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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