Aspire Senior Living Excelsior Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Excelsior Springs, Missouri.
- Location
- 1003 Meadowlark Lane, Excelsior Springs, Missouri 64024
- CMS Provider Number
- 265821
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Aspire Senior Living Excelsior Springs during CMS and state inspections, most recent first.
Food Storage and Emergency Supply Deficiencies: Facility staff failed to store and monitor food in accordance with professional standards. Observations showed an inadequate emergency food stock, dented and rusted cans kept in the storeroom and on the floor, bulk items without use-by dates, and defrosting ground beef without proper dating. The DM stated the emergency supply was not enough for 3 days and that dented cans had been kept for weeks before being turned in for credit.
Surveyors found that staff failed to provide proper perineal care and hygiene to two dependent residents requiring assistance with ADLs. For a cognitively impaired resident with multiple diagnoses, a CNA did not separate skin folds or clean all areas where urine or feces could have contacted the skin during peri-care. For another resident with a suprapubic catheter, recurrent UTIs, and irritant contact dermatitis, the ADON reused a single cleansing wipe by folding it and wiping the perineal area multiple times, despite other staff and leadership stating that wipes should only be used once. These practices did not follow the facility’s peri-care policy requiring separate wipes for each stroke and thorough cleansing of all affected areas.
Failure to obtain written consent before starting psychotropic medications for three residents. One resident had intact cognition and was receiving diazepam and quetiapine, while two others had impaired cognition and were receiving antianxiety, antipsychotic, and antidepressant medications. Records showed no signed consents before or after the meds were started, and interviews confirmed the DPOA had not been asked to sign paperwork and staff were unsure who was responsible for obtaining psychotropic consent.
A facility failed to refund or provide final accounting for several residents’ trust funds after discharge or death and failed to send a required letter to a resident whose account was within $200 of the SSI resource limit. Records showed one resident with moderate cognitive impairment and multiple diagnoses had a trust balance above the state limit, while several discharged or deceased residents still had remaining funds in their accounts. The BO said the missed refunds and notice were oversights.
Failure to Maintain Privacy During Personal Care: Staff failed to provide privacy for two residents during care. For one resident with dementia and total dependence on staff, CNAs performed peri-care with the curtain between the resident and roommate left open, exposing the resident in full view of the roommate. For another resident receiving wound care for a stage 3 pressure ulcer, the ADON and an LPN left the resident’s perineal area and buttock exposed while the window blinds were open to the parking lot.
Failure to complete Level I PASARR screening before admission for two residents. One resident had impaired cognition, dependence for ADLs, and diagnoses of anxiety, depression, and psychotic disorder; the care plan also noted dementia-related aggression risk and use of psychotropic and anti-anxiety meds. The medical record had no PASARR documentation, and the SSD, Administrator, and DON all acknowledged the screening should have been completed before admission.
Failure to Provide Ordered Nutritional Supplements: Multiple residents with cognitive impairment and nutritional concerns had physician orders for Mighty Shake three times daily, but MARs and nursing notes showed repeated missed doses because the supplement was out of stock, frozen, or otherwise unavailable. Staff interviews showed CMTs and CNAs knew the shakes were not being given, but the nurse, physician, and RD were not notified when the ordered supplements were missed.
Failure to document and store oxygen equipment properly affected several residents receiving O2 therapy. Staff did not date oxygen tubing or humidifier equipment as ordered, and two residents had oxygen accessories not properly stored or attached at the bedside. Residents involved had significant respiratory diagnoses including COPD, respiratory failure, HF, and Alzheimer’s disease, and one resident reported dry, bloody nasal passages and wanting humidified O2.
A facility failed to assess entrapment risk before installing bed rails and failed to verify that bed dimensions were appropriate for residents’ size and weight for three residents. One resident with MS and a history of falls had bilateral cane rails in use and had prior incidents in which an arm and shoulder were caught in the rail. Two other residents with severe cognitive impairment and fall histories also had bilateral cane rails, but their assessments lacked height, weight, and documentation that the rails fit their size and weight. Staff interviews showed the MDS Coordinator, DON, Maintenance Director, and Administrator were not aware of entrapment assessments, and the bed rail process did not include resident measurements or bed dimension checks.
Failure to Inspect Bed Frames and Bed Rails for Entrapment: Three residents who used bilateral cane rails or side rails had records showing bed rail use, falls, and significant medical issues such as MS, severe cognitive impairment, heart failure, and atrial fibrillation. One resident’s notes documented a fall in which the shoulder got caught in the bed rail. For all three residents, the record lacked documentation of pre-installation inspection of the bed frame and mattress and lacked evidence of an ongoing inspection process to identify possible entrapment areas. Staff interviews showed the CNA, LPN, MDS Coordinator, Maintenance Director, DON, and Administrator were not aware of an ongoing entrapment assessment process.
Medication refrigerator temperature was not being monitored in the CMT medication room, and surveyors found no temperature log sheet or logbook available. The refrigerator’s freezer compartment had ice buildup extending past the edges, and it contained two Mighty Shakes and Arformoterol for a resident. The CMT said he/she did not check the temperature and did not know where the log was kept, while the Administrator, RN, CMT, and DON gave differing accounts of who was responsible for checking and recording the refrigerator temperature.
The facility failed to maintain a qualified licensed administrator as required by state laws. Administrator A's license had expired, and she was unaware of this until it was brought to her attention. Despite receiving multiple renewal reminders from the BNHA, she claimed not to have received them. Administrator B was hired temporarily to fulfill the role until Administrator A's license could be renewed. The facility lacked a policy for checking administrator license status, which they plan to implement.
Expired medications, including Skintegrity Hydrogel, cranberry tablets, and Thera-M multi-vitamins, were found in two medication storage rooms. Staff interviews revealed confusion about who is responsible for checking and removing expired medications, despite the Administrator stating that monthly audits are conducted.
The facility failed to properly store nutritional supplements for 17 residents, as observed during an inspection. A box of thawed Mighty Shakes in the walk-in refrigerator was not labeled with a thaw or use-by date, and the Dietary Manager was unaware of the required time frames. This oversight had the potential to cause foodborne illnesses.
A facility failed to properly clean and disinfect blood pressure cuffs after use on a resident, as observed during a medication pass. A CMT used alcohol prep pads instead of disinfectant wipes, contrary to facility policy. Interviews with staff revealed inconsistencies in understanding and implementing cleaning protocols.
A facility failed to maintain an effective Antibiotic Stewardship Program, leading to the inappropriate prescription of antibiotics for a resident with chronic kidney disease and no UTI symptoms. Despite the absence of symptoms, a urinalysis was ordered, and antibiotics were prescribed before culture results were available. The resident was later found resistant to the prescribed antibiotic, necessitating a change in medication. Interviews revealed non-compliance with the facility's protocols, highlighting the need for better adherence to the McGeer Criteria.
Food Storage and Emergency Supply Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when facility staff failed to properly monitor food items for expiration dates, dispose of dented cans in a timely manner, and maintain a three-day emergency food supply. During observation of the dry storeroom, the emergency food stock contained only 12 cans of food and three bags of pasta for emergencies. The storeroom also contained two #10 cans of peas on the ground under the can storage rack, three rows of six dented #10 cans marked Do Not Use in the rack, and three additional dented #10 cans on the ground, including two being used as door stops and one lying under a storage rack; one can was rusted and bulging on the side. Large plastic bins of breadcrumbs, gram cracker crumbs, flour, and sugar were also observed with dates but no use-by dates. The Dietary Manager stated there was not enough food in the emergency supply to feed residents for three days and that the dented cans had been kept since the Thanksgiving and Christmas time frames, with disposal delayed until the credit was large enough to matter. In the walk-refrigerator, ground beef was defrosting with a received date but no date showing when defrosting started or a use-by date. The Dietary Manager stated the hamburger had been placed in the refrigerator sometime during the weekend, and later stated that food items should never be stored on the ground, bulk items should have a use-by date, and defrosting food should be dated. The Registered Dietician also stated opened items should be resealed and dated, food should not be stored on the ground, defrosted meat should have a date showing when it is to be used or when defrosting started, and dented cans should be turned in at the next available opportunity.
Failure to Provide Proper Perineal Care and Hygiene for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate perineal care and maintain personal hygiene for dependent residents requiring assistance with ADLs. For one resident with Alzheimer’s disease, respiratory failure, and heart failure, who was cognitively impaired and totally dependent on staff for ADLs, surveyors observed two CNAs performing peri-care. CNA B wiped the resident’s inner thighs with separate cleansing wipes but then used a single wipe twisted into the front of the genital opening without spreading the surrounding skin folds, and wiped down the leg and up to the anus without separating folds or verifying cleanliness. CNA B later stated they would normally wipe all areas exposed to urine or feces but did not do so in this instance. Other staff, including another CNA, the ADON, DON, and the Administrator, stated that proper peri-care requires cleaning all areas where urine or stool could touch and providing privacy, and an anonymous employee reported that CNA B did not provide good peri-care to two residents who required toileting and changing. For another resident who was cognitively intact but dependent on staff for personal hygiene and had diagnoses including irritant contact dermatitis due to friction or contact with body fluids, UTI, neuromuscular dysfunction of the bladder, and a suprapubic catheter, the ADON was observed providing peri-care after wound treatment. The ADON cleaned the perineal area by wiping once down the middle, then folded the same wipe and used it again down the middle of the perineal area, contrary to facility expectations. In an interview, the ADON stated that a cleansing wipe could be folded and reused up to three times during peri-care, while a CNA, the Administrator, and the DON each stated that a cleansing wipe should only be used once and should not be folded and reused. These observations and interviews showed that staff did not consistently follow the facility’s perineal care policy, which required thorough cleansing of all areas where urine or feces could contact the skin, use of separate wipes for each stroke, and proper technique to maintain hygiene and assess for skin breakdown.
Failure to Obtain Written Consent Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks and benefits of proposed care and treatments by not obtaining written consent before starting psychotropic medications for three sampled residents. Review of the facility policy showed residents have the right to be fully informed in advance about care and treatment changes that may affect their well-being. Record review showed Resident #44 had intact cognition, diagnoses of anxiety and depression, and was receiving diazepam and quetiapine, but there were no consents signed by the resident or representative before or after these medications were started. Resident #68 was not cognitively intact, had diagnoses of anxiety, depression, and psychotic disorder, and was receiving antianxiety, antipsychotic, and antidepressant medications, but the record also contained no signed consents before or after the medications began. Resident #9 had impaired cognition and diagnoses of depression, anxiety, and PTSD, and was receiving trazodone, venlafaxine, and bupropion, yet the electronic record showed no consents signed by the resident or representative before or after medication administration. During interviews, the resident's DPOA stated the facility did not have him/her sign paperwork regarding new medications, side effects, or medication changes. An RN stated written consent had not been obtained before starting psychotropic medications and was unsure who was responsible for obtaining it. The ADON, DON, and Administrator each stated residents and their representatives should know the potential side effects and reasons for taking psychotropic medications before taking them, and that signed psychotropic consents should be in place.
Resident trust funds not refunded or accounted for timely, and required balance notice not sent
Penalty
Summary
The facility failed to provide personal funds and a final accounting within 30 days after discharge or death for five residents and failed to notify one resident by letter when the resident’s trust account was within $200 of the SSI resources limit. Facility policy stated that resident trust accounts nearing the state maximum required notification by letter, and that refunds for discharged residents were to be completed within 5 business days, with resident funds reconciled no later than 30 days. The deficiency affected six of 18 residents sampled, with a facility census of 78. Resident #7 had moderate cognitive impairment on MDS and diagnoses including anemia, diabetes, hip fracture, seizure disorder, bipolar disorder, psychotic disorder, and anxiety disorder. Records showed the resident’s trust account balance was $8,072.15, and the BO stated she had discussed spending down the balance but did not know a letter was required when the account was within $200 of the state limit. Records also showed Resident #85 discharged with $3.51 in the trust account, Resident #86 expired with $268.27, Resident #87 discharged with $10.00, Resident #88 discharged with $57.31, and Resident #89 had $27.38 in the trust account; the BO stated these residents should have been refunded or their money sent back to Medicaid, and that these were oversights. The Administrator stated resident accounts should be reconciled and refunded as necessary within 5 days of discharge but no later than 30 days.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy for two residents during personal care. For one resident with Alzheimer’s disease, respiratory failure, heart failure, and total dependence on staff for care, CNA B and CNA C performed peri-care while the resident’s room door was closed but the curtain between the resident and the roommate remained open. The resident was exposed and the peri-care was performed in full view of the roommate. CNA B stated he/she would normally provide proper privacy between the resident and the roommate but did not. Staff interviews confirmed that privacy should be provided during peri-care by pulling the curtain. For another resident who was cognitively intact, dependent on staff for toileting, bathing, and dressing, and had a stage 3 pressure ulcer of the right buttock, colostomy, hospice status, and an above-the-knee amputation, the ADON and an LPN provided wound care while the resident’s perineal area and buttock were exposed. During the care, the window blinds next to the resident’s bed were open to the parking lot, and a car drove into the parking lot and parked while care was being provided. The resident said he/she just wanted staff to do what they needed to do regarding privacy during care. Multiple staff members stated that blinds should be closed and privacy provided when the resident would be exposed.
Failure to Complete PASARR Screening Before Admission
Penalty
Summary
The facility failed to ensure that a Level I PASARR assessment was completed before admission for two residents. The deficiency was identified during interview and record review and involved Resident #68 and Resident #80, two of 18 sampled residents in a facility census of 78. The facility’s PASARR policy, dated 1/30/24, stated that each resident must be screened for a mental disorder or intellectual disability prior to admission and that the initial Level I identification is completed before admission to the facility. For Resident #68, the quarterly MDS dated 11/6/25 showed cognition was not intact, the resident was dependent on staff for activities of daily living, and diagnoses included anxiety, depression, and psychotic disorder. The care plan revised 11/6/25 noted potential physical aggression related to dementia, psychotropic medication use related to psychosis, and anti-anxiety medication use related to an anxiety disorder. The medical record contained no documentation that a Level I PASARR had been completed. During interviews, the SSD said the facility did not have documentation of a Level I PASARR and was not sure if one had been completed, the Administrator said a Level I PASARR should be in the EMR and that the facility attempts to obtain it from the prior facility, and the DON said the Level I PASARR should have been completed before admission and was not sure of the policy when a resident is admitted from another facility.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide Mighty Shakes as ordered for multiple residents and did not notify the physician or RD when the supplements were not given. Resident #5 had diagnoses including dementia, low blood pressure, and anxiety, and was assessed as needing partial assistance with bed mobility and toileting and as having a potential nutritional problem related to dementia. The resident had a physician order for Mighty Shake three times a day, but the MAR showed multiple missed doses in December 2025 and January 2026. Nursing notes repeatedly documented that the supplement was unavailable, and there was no documentation that the physician or RD had been notified. Resident #4 had severe cognitive impairment, was dependent for toileting and bed mobility, and had diagnoses including heart failure, high blood pressure, and anemia. The resident also had a physician order for Mighty Shake three times a day, but the MAR showed multiple missed doses in December 2025 and January 2026. Nursing notes again documented that the shakes were out of supplement, and the record did not show that the physician or RD had been notified. The resident's care plan did not address the resident's use of health shakes. Resident #68 was dependent for activities of daily living, not cognitively intact, and had diagnoses of Parkinson's disease, muscle weakness, and Alzheimer's disease. The resident was on hospice care and had an order for Mighty Shake three times a day for weight loss with meals. The MAR showed missed doses because the shakes were frozen or not available on several occasions in December 2025 and January 2026. Staff interviews showed CNAs did not give the shakes, nurses and CMTs gave them, CMTs sometimes told dietary when supplies were low, and staff did not notify the nurse or physician when residents did not receive the ordered shakes. The DON and administrator stated that the physician should be notified when ordered shakes were not given.
Failure to Document and Store Oxygen Equipment Properly
Penalty
Summary
Proper respiratory care was not provided when staff failed to document the date oxygen tubing was cleaned or changed for four residents and failed to properly store oxygen accessories at the bedside for two residents. The facility’s Oxygen Administration policy, dated April 2006, did not provide specific guidance for changing disposable humidifiers, changing oxygen tubing, or regular intervals for checking and cleaning oxygen equipment, masks, tubing, nasal cannulas, or oxygen cylinder contents and humidifier fluid levels. Resident #9 had diagnoses including respiratory failure, diabetes, and PTSD, and was dependent on staff for showers and needed assistance with all other ADLs. Although the physician order summary directed staff to change oxygen tubing and humidifier every Sunday day shift, observations on 1/5/26, 1/7/26, and 1/8/26 showed a humidifier bottle dated 12/28 attached to the concentrator, an empty bag tied to the concentrator dated 7/27, nebulizer tubing sitting open on the nightstand dated 12/28, and oxygen tubing in use with no date written on it. Resident #29 had respiratory failure, diabetes, and heart failure, required substantial assistance with care, and was ordered oxygen at 2 liters per minute via nasal cannula with tubing and humidifier changed every Wednesday night shift. During observation and interview, the resident reported needing oxygen all the time, having dry nose and frequent bloody nose, and having oxygen tubing without a date; the oxygen storage bag was dated 1-1, no humidifier bottle was attached, and tubing on the portable tank was also not dated. Later observation showed the tubing had been replaced and dated, but no humidifier bottle was attached as ordered. Resident #39 had Alzheimer’s disease, respiratory failure, and heart failure, was dependent on staff for showers, transfers, and dressing, and had an order for oxygen tubing and humidifier changes every Sunday day shift. Observation showed an empty, undated humidifier bottle attached to the concentrator, undated oxygen tubing, and an undated supply storage bag; later the humidifier bottle was changed and dated, but the tubing attached to the portable oxygen cannister was still not dated. Resident #2 had COPD, trouble breathing at rest and with exertion, was on hospice, and was dependent on nursing staff for oxygen equipment needs. The resident had an order for oxygen as needed and for tubing and humidifier changes every Sunday night shift, but observation showed the nasal cannula tubing in use was not dated and no humidifier bottle was attached to the concentrator. The resident stated a humidifier was desired because the nose became dry while wearing oxygen.
Failure to assess bed rail entrapment risk and bed dimensions
Penalty
Summary
The facility failed to assess residents for entrapment risk from bed rails before installation and failed to ensure the bed dimensions were appropriate for the residents’ size and weight for three sampled residents. The facility policy dated 1/30/2024 required correct installation and maintenance of bed rails, assessment of entrapment risk prior to installation, confirmation that bed dimensions were appropriate, and routine inspection and preventive maintenance. Survey review found that staff did not complete entrapment assessments and did not measure resident beds before installing the rails. For one resident with multiple sclerosis, dependence for toileting and bed mobility, incontinence, and a history of falls, the care plan and physician order included bilateral cane rails for bed mobility and positioning. Nursing notes documented a fall in which the resident’s arm was caught behind the resident and another event in which the resident said a shoulder got caught in the bed rail after reaching off the side of the bed. During observation, the resident was seen in bed with both bilateral cane rails in the up position and stated the rails helped with getting out of bed. For two other residents, both with severe cognitive impairment and histories of falls, the records showed bilateral cane rails or side rails in use and physician orders for bilateral cane rails for bed mobility and positioning. However, the bed rail assessments did not include the residents’ height or weight and did not document that the installed rails were appropriate to the residents’ size and weight. Staff interviews confirmed that nurses, therapy, and maintenance handled the rail process, but the MDS Coordinator, DON, Maintenance Director, therapy supervisor, and Administrator were not aware of entrapment assessments or did not include resident measurements or bed dimensions in the assessment process.
Failure to Inspect Bed Frames, Mattresses, and Bed Rails for Entrapment
Penalty
Summary
The facility failed to complete regular inspections of bed frames, mattresses, and bed rails to identify possible entrapment areas for three sampled residents who used bilateral cane rails or side rails. For Resident #51, the quarterly MDS showed no cognitive impairment, dependence on staff for toileting and bed mobility, incontinence, and a history of falls with injury. The care plan and POS documented use of bilateral cane rails for bed mobility and positioning, and nursing notes described a fall in which the resident’s shoulder got caught in the bed rail after reaching off the side of the bed. The record contained no documentation that the bed frame and mattress had been inspected before the rails were installed or that ongoing inspections had been completed. For Resident #4, the quarterly MDS showed severe cognitive impairment, dependence on staff for toileting and bed mobility, one fall with injury, and diagnoses including heart failure, high blood pressure, and anemia. The bed rail assessment documented a history of falls and bilateral assist bars, but no height or weight was recorded and there was no documentation confirming the rails were appropriate to the resident’s size and weight. The care plan and POS documented use of bilateral cane rails for bed mobility and positioning, and the record again lacked documentation of pre-installation inspection of the bed frame and mattress or regular ongoing inspection for possible entrapment. A third resident record also showed severe cognitive impairment, delusions, use of side rails, set-up help with bed mobility, and a history of falls prior to admission, with diagnoses including atrial fibrillation, high blood pressure, and BPH. The care plan did not address side rail use, and the bed rail assessment again lacked height and weight information and did not confirm the rails were appropriate to the resident’s size and weight. Interviews with CNA, LPN, MDS Coordinator, Maintenance Director, DON, and Administrator showed the staff understood maintenance installed the rails, but they did not know of any entrapment assessments or ongoing process for measuring the bed frame, mattress, and bed rails.
Medication Refrigerator Temperature Not Monitored
Penalty
Summary
Drugs and biologicals were not stored under proper temperature controls in the CMT medication room because the facility could not provide a record showing that the refrigerator temperature had been monitored. During observation on 01/06/2026 at 3:20 P.M., surveyors found no refrigerator temperature log sheet on the refrigerator and no logbook in the medication room. The freezer compartment of the refrigerator had ice buildup extending past the edges of the compartment, and the refrigerator contained two Mighty Shakes and Arformoterol for Resident #9. The facility did not provide a medication storage policy. During interview, the CMT said he/she did not check the refrigerator temperature and was not sure where the temperature log was kept, and was not sure how long the ice had been built up in the freezer compartment. The Administrator said the medication refrigerator temperature log was usually kept on the counter above the refrigerator and that the night shift CMT was responsible for checking the temperature. RN A said the medication refrigerator temperature should be checked every shift, while CMT B said he/she did not check the temperature and was not aware of the ice buildup. The DON said the medication refrigerator temperature should be checked and recorded every night.
Failure to Maintain Licensed Administrator
Penalty
Summary
The facility failed to maintain a qualified licensed administrator on duty from the specified dates, as required by state laws. The facility's policy mandates that the governing board appoints an administrator who is duly licensed in accordance with federal and state requirements. However, a review of the Missouri Association of Nursing Home Administrators license registry revealed that Administrator A was not listed as a current Missouri Licensed Administrator. During an interview, Administrator A admitted she was unaware her license had expired and planned to contact the Missouri Board of Nursing Home Administrators (BNHA) to address the issue. Documentation from the BNHA indicated that Administrator A had been sent multiple reminders to renew her license, which she claimed not to have received. Upon realizing her license had expired, she informed the corporate office, and Administrator B was hired to temporarily fulfill the role of licensed administrator. Administrator B confirmed her temporary role and noted that the facility lacked a policy for checking the license status of administrators, which they plan to implement in the future.
Expired Medications Found in Storage Rooms
Penalty
Summary
The facility failed to remove expired medications from two medication storage rooms, which could potentially expose residents to unsafe or ineffective treatments. During an observation, three tubes of expired Skintegrity Hydrogel, used for treating pressure ulcers, were found in a medication room. Two of these tubes had expired in May 2024, and one had expired in October 2023. A Licensed Practical Nurse (LPN) confirmed the expiration and removed the tubes. Additionally, in another medication room, two bottles of expired cranberry tablets and three bottles of expired Thera-M multi-vitamins were discovered. A Certified Medication Aide (CMT) confirmed these medications were expired and removed them. Interviews with staff revealed a lack of clarity regarding the responsibility for checking and removing expired medications. The LPN mentioned that a supply person checks expiration dates daily, while the CMT believed someone else was responsible for checking and destroying expired medications. The Infection Preventionist nurse was unaware of who checks for expired medications, although they knew someone destroys them. The Administrator stated that nurses and CMTs conduct monthly audits and check expiration dates when restocking, but the presence of expired medications indicates a lapse in this process.
Improper Storage of Nutritional Supplements
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, specifically concerning the storage of nutritional supplements for 17 residents. During an inspection, it was observed that a box containing 59 four-ounce thawed Mighty Shakes, a nutritional supplement, was stored in the walk-in refrigerator without being labeled with a thaw or use-by date. The box was dated 08/22/24, but the significance of this date was unclear. Each carton of Mighty Shakes had a warning label indicating that the product should be stored frozen, thawed below 40 degrees, and used within 14 days. Additionally, seven Mighty Shakes in the reach-in refrigerator were also not labeled with a thaw or use-by date. The Dietary Manager (DM) admitted during an interview that she was unaware of the thawing and use-by time frames indicated on the Mighty Shake carton. Although there was a date on the box, the DM did not know who wrote it or what it signified. This lack of awareness and proper labeling had the potential to result in foodborne illnesses for the residents consuming these nutritional supplements.
Inadequate Cleaning of Patient Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of patient equipment, specifically blood pressure cuffs, after use on a resident. During a medication pass, a Certified Medication Aide (CMT) used a wrist cuff and a manual blood pressure cuff on a resident and placed them on the medication cart without adequately cleaning the cart or using a barrier. The CMT cleaned the cuffs with alcohol prep pads, which was not in accordance with the facility's policy that required the use of disinfectant wipes for such equipment. The CMT also cleaned her stethoscope with an alcohol prep pad and placed it back around her neck. Interviews with the CMT, Director of Nursing (DON), Infection Preventionist (ICP), and Administrator revealed inconsistencies in the understanding and implementation of the facility's cleaning protocols. The DON and Administrator both expected equipment to be cleaned after each use, with the Administrator specifying the use of disinfectant wipes for blood pressure cuffs. The ICP provided training on cleaning patient care equipment several times a year and stated the dry time for the facility's sanitizing wipes was four minutes. However, the CMT was unsure of the dry time for the cleaning products used.
Inadequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program, as evidenced by the inappropriate prescription of antibiotics for a resident. The resident, who was admitted with chronic kidney disease stage 3 and a urinary tract infection, was noted to have increased confusion but no urinary symptoms. Despite this, a urinalysis was ordered, and antibiotics were prescribed before the culture and sensitivity results were available. The resident's urinalysis showed positive results for gram-negative bacilli, but the culture results were not immediately available. The physician ordered Bactrim DS for a urinary tract infection, although the resident did not exhibit any signs or symptoms of a UTI. The culture and sensitivity report later indicated resistance to the prescribed antibiotic, leading to a change in medication to Gentamicin. Interviews with the Infection Preventionist and the Director of Nursing revealed that the facility did not adhere to its antibiotic stewardship protocol, which included using the McGeer Criteria for Infection Surveillance. The staff was aware that the resident did not meet the criteria for a urinalysis, and antibiotics were prescribed without appropriate justification. The Director of Nursing acknowledged the need for continuing education to ensure compliance with the facility's protocols.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
