Brookhaven Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 3405 West Mt Vernon, Springfield, Missouri 65802
- CMS Provider Number
- 265835
- Inspections on file
- 29
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Brookhaven Nursing & Rehab during CMS and state inspections, most recent first.
A resident with cellulitis, gangrene, and a necrotic left great toe did not receive wound care fully consistent with the wound care FNP’s documented plan of care. The FNP repeatedly ordered daily cleansing with hypochlorous acid, Betadine application, and calcium alginate dressings cut to fit inside the wound, with changes daily and as needed. However, nursing staff entered physician orders that reduced treatment to every other day and omitted or altered the calcium alginate directions, and these discrepancies persisted over multiple weeks. Interviews with LPNs, an RN, the FNP, the physician, the DON, and the Administrator showed that all expected the electronic orders to match the FNP’s recommendations, but they were unaware that the entered orders did not reflect the specialist’s specified frequency and application method, resulting in a failure to provide care per standards of practice and the certified wound care plan.
A resident with dementia and schizophrenia requested pain medication and, after being told to wait, became agitated and struck the medication cart. The CMT responded in a raised voice with a statement perceived as threatening by multiple staff, such as warning it would be the last time the resident hit the cart. Staff interviews and documentation confirmed the CMT's conduct was disrespectful and violated the resident's right to dignity and respect.
A resident with multiple chronic conditions did not receive scheduled medications at the prescribed times, with morning medications administered over two hours late. Staff interviews confirmed that medication administration was frequently delayed due to high workloads, and residents had complained about late medications. The facility lacked an effective system to ensure medications were given within the required time frames.
A resident with complex psychiatric and medical needs did not receive proper pharmaceutical services after returning from the hospital due to staff failing to accurately transcribe, clarify, and administer new medication orders. Several prescribed medications were omitted or incorrectly entered into the EHR, and staff did not consistently document medication administration or reasons for omissions, resulting in the resident not receiving all ordered medications.
The facility failed to enforce its smoking policy, allowing residents to keep smoking materials in their rooms and on their person, contrary to the policy that requires these items to be stored at the nurses' station. Residents with various health conditions, including COPD, were found smoking unsupervised, and staff interviews revealed a lack of adherence to the policy. The Director of Nursing and the Administrator were unaware of these practices, indicating a lack of oversight.
The facility failed to serve food at the required temperature, with residents reporting cold and unappetizing meals. Observations confirmed that food temperatures were below the required 120 degrees Fahrenheit, and staff acknowledged resident dissatisfaction with meal quality.
The facility failed to follow proper food safety protocols by stacking wet dishes, which could lead to contamination. Observations showed numerous dishes stacked upside down with trapped water droplets, contrary to the facility's policy and FDA guidelines. Interviews with dietary staff confirmed the expectation for dishes to be air-dried before stacking, highlighting a deficiency in practice.
The facility failed to maintain an effective infection control program, with deficiencies in TB screening for new hires, improper catheter maintenance, and inadequate hand hygiene and medication administration practices. Staff did not consistently follow protocols for sanitizing shared medical equipment, such as glucometers, increasing the risk of cross-contamination.
A facility failed to complete the required PASARR for a resident with paranoid schizophrenia and major depressive disorder prior to or upon admission. The resident's care plan addressed delusions, but the absence of a PASARR indicates a failure to ensure appropriate care and services. The Business Office Manager could not locate the PASARR documentation, and the Social Services Director stated they try to complete these forms within 48 hours of admission.
A resident with a history of cerebral infarction and Parkinson's disease had inconsistencies in their code status documentation. While the resident's face sheet and care plan indicated a DNR status, the physician's order sheet listed them as a full code. Staff interviews confirmed that the code status should be consistent across all records, but discrepancies were found, highlighting a failure in maintaining accurate documentation.
A resident with a history of osteomyelitis and MRSA experienced a deficiency in care due to the facility's failure to document and treat a worsening elbow wound. Despite the resident's complaints and the presence of drainage, staff did not maintain current treatment orders or consistently document assessments. Interviews revealed communication issues among healthcare providers, contributing to the deficiency.
A facility failed to document regular wound assessments for a resident with a pressure ulcer on the right hip. Despite having a care plan and physician orders, the facility did not consistently record assessments or measurements, leading to a deficiency in care. Interviews revealed that wound assessments were not regularly performed unless by a visiting clinic, and documentation was acknowledged as an issue by the ADON.
Two residents in the facility did not receive their prescribed medications due to unavailability. One resident, with a vitamin B12 deficiency, missed numerous doses of B Complex-Vitamin B12 tablets, while another resident, with constipation and pain, missed doses of Senna Plus and acetaminophen. Staff interviews revealed a lack of communication and follow-up regarding medication availability, and the facility's policy on medication administration was not adhered to, resulting in a deficiency in pharmacy services.
The facility experienced a 12.5% medication error rate due to incorrect Vitamin D3 dosing and unavailability of acetaminophen and Senna Plus for two residents. Additionally, fast-acting insulin was administered without ensuring a meal within the recommended time frame. Staff interviews revealed procedural lapses in medication administration and communication about unavailable medications.
A resident with diabetes was administered rapid-acting insulin but was not provided a meal or snack within the recommended time frame. Observations showed a delay of 54 minutes before a meal was served, contrary to staff interviews indicating meals should be provided within 30 minutes. The facility's policy lacked specific guidance on insulin administration timing.
Failure to Align Wound Care Orders With Wound Specialist’s Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in accordance with the wound care specialist’s recommendations and to correctly enter and follow wound treatment orders for a resident with cellulitis and gangrene. The resident was cognitively intact, required moderate assistance for transfers, and had impaired skin integrity with bilateral lower leg cellulitis and a necrotic left great toe with dry gangrene. The facility’s wound care policy required specific treatment orders and care plans that reflected the current wound status and appropriate goals and approaches. The care plan and physician orders were supposed to be based on the wound care FNP’s weekly assessments and written recommendations. The wound care FNP documented multiple progress notes specifying that the left great toe wound should be cleansed with hypochlorous acid without rinsing, painted with Betadine, and covered with a calcium alginate dressing cut to fit inside the wound edges, with dressing changes to occur daily and as needed. These recommendations were documented on several dates, including 12/12/25, 12/19/25, and 01/02/26, and the FNP indicated that all orders would remain in effect until discontinued, revised, or replaced. Despite this, the facility’s Physician Order Sheets did not consistently reflect these directions. On 12/15/25, the order for the left big toe was entered as cleansing with hypochlorous acid and painting with Betadine with treatment once every other day, and it did not include the calcium alginate dressing as ordered by the FNP. On 12/19/25, the order was updated to include calcium alginate but specified application to the crevice between the toe and foot once every other day, rather than daily and cut to fit inside the wound as directed by the FNP. The January 2026 Physician Order Sheet still did not reflect the correct daily frequency or the instruction to cut the calcium alginate to fit inside the wound, even after the FNP’s 01/02/26 note again ordered daily dressing changes with calcium alginate cut to fit in the wound base. Nursing staff interviews showed that LPNs believed they were to follow the wound care FNP’s recommendations and that a nurse would enter those recommendations into the computer for the physician to sign, but they were unaware that the treatment frequency had been decreased to every other day and that this change did not match the FNP’s recommendations. The FNP stated that he/she expected staff to follow his/her and the physician’s wound care orders, did not order a decrease in treatment frequency, and was unaware that the facility had reduced the frequency. The physician and DON both stated they expected nurses to enter and follow orders that matched the FNP’s recommendations, but they did not know the entered orders differed from those recommendations. This series of incorrect order entries and failure to align the POS with the wound care specialist’s documented plan of care led to the facility not providing wound care per standards of practice and per the wound care specialist’s certified plan of care for the resident’s left great toe wound. The resident’s care plan updates reflected some of the FNP’s clarifications, such as painting the big toe with Betadine and placing calcium alginate around the toe in the crevice between the toe and healthy tissue, and noted that wound care to the left leg should be done every other day and as needed. However, these care plan entries still did not fully match the FNP’s written orders for daily dressing changes and for calcium alginate to be cut to fit inside the wound edges. Staff interviews confirmed that the process relied on nurses to transcribe the FNP’s recommendations into physician orders, and that the DON and Administrator expected those orders to match the FNP’s notes. The discrepancy between the FNP’s documented orders and the actual physician orders entered and followed by staff, particularly regarding the frequency of treatment and the method of applying calcium alginate, constituted the failure to provide care according to standards of practice and the wound care specialist’s recommendations for this resident. The deficiency is further supported by the fact that multiple staff members, including LPNs, an RN, the FNP, the physician, the DON, and the Administrator, acknowledged that the facility’s practice was to follow the wound care FNP’s recommendations and that the orders in the computer should match those recommendations. Nonetheless, the POS entries did not reflect the FNP’s specified daily dressing changes and detailed application instructions for calcium alginate. The FNP also noted that increased drainage from the toe was related to the resident’s increased activity and did not warrant a decrease in treatment frequency, yet the facility’s orders reduced the frequency to every other day without a corresponding recommendation from the FNP. These documented inconsistencies between the wound care specialist’s certified plan of care and the orders actually entered and followed by the facility staff form the basis of the cited deficiency.
Resident Rights Violated by Disrespectful and Threatening Staff Conduct
Penalty
Summary
A deficiency occurred when a Certified Medication Tech (CMT) spoke to a resident in a disrespectful and threatening manner during a medication pass. The resident, who had diagnoses including unspecified dementia and schizophrenia, approached the medication cart to request pain medication, reporting significant pain at the time. The CMT told the resident to wait, which led to the resident becoming agitated, striking the medication cart, and using derogatory language toward the CMT. In response, the CMT raised their voice and made a statement interpreted by multiple witnesses as threatening, such as, "if you hit my cart again, that will be the last time you hit it," or similar variations. Multiple staff members, including CNAs, nurses, and supervisors, either overheard or were present during the incident and described the CMT's tone as raised, disrespectful, and threatening. Written and verbal statements from staff corroborated that the CMT's response was inappropriate and not in line with resident rights or facility policy, which requires residents to be treated with dignity and respect. The resident expressed feeling uncomfortable and not wanting to be around the CMT due to the interaction. The facility's own policy emphasizes the right of residents to be treated with consideration and respect, and staff interviews confirmed that threatening language toward residents is unacceptable. The Director of Nursing and Administrator both acknowledged that the CMT's statements were disrespectful and should not have been made. The incident was reported and documented by several staff, and the situation was de-escalated after intervention by other staff members.
Failure to Administer Medications Timely According to Policy and Standards
Penalty
Summary
The facility failed to ensure that medications were administered to a resident in accordance with professional standards of quality and facility policy. Observation, interview, and record review revealed that a resident with multiple diagnoses, including bipolar disorder, anxiety disorder, heart failure, and hypertension, did not receive scheduled medications at the prescribed time. The resident's Medication Administration Record (MAR) indicated several medications were scheduled for administration at 8:00 A.M., but on the observed date, these medications were not administered until 10:15 A.M., which was two hours and fifteen minutes after the scheduled time. The resident also reported that medications were frequently not given at the scheduled times, including evening doses being administered late. Interviews with staff, including Certified Medication Technicians (CMTs), Registered Nurses (RNs), Certified Nurse Aides (CNAs), and the Director of Nursing (DON), confirmed that there were ongoing issues with timely medication administration. Staff consistently stated that medications should be administered within one hour before or after the scheduled time, and that administration outside this window is considered late and a medication error. Staff attributed the delays to high medication loads, with one CMT responsible for administering medications to up to 58 residents across multiple halls, making it difficult to adhere to scheduled times. Additional interviews with CNAs revealed that they had received complaints from residents about late medication administration, particularly in the afternoons. The DON and Administrator acknowledged the staffing assignments and the expectation that medications be administered as ordered, but were not aware of the extent of the delays until brought to their attention during the survey. The facility did not have an effective system in place to ensure timely medication administration, resulting in repeated late administration of medications to residents.
Failure to Accurately Transcribe and Administer Medications After Hospital Discharge
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident following discharge from the hospital. Upon the resident's return, staff did not properly transcribe or clarify new medication orders, resulting in discrepancies between the hospital discharge instructions and the medications entered into the facility's electronic health record (EHR). Several medications ordered at discharge, including fluphenazine, Seroquel, ketoconazole, clotrimazole, and Miralax, were not added to the physician's order sheet, and there were inconsistencies in the dosages and administration instructions for other medications such as gabapentin and oxybutynin. Additionally, staff failed to document administration or reasons for omission of multiple medications on the Medication Administration Record (MAR) for the day of the resident's return. The resident involved had a complex psychiatric and medical history, including schizoaffective disorder, bipolar type, PTSD, depression, and a history of suicidal ideation. The care plan required close monitoring, administration of psychotropic medications as ordered, and assessment for side effects. Despite these needs, the facility did not ensure that the resident's medication regimen was accurately reconciled or administered as prescribed after the hospital stay. Interviews with staff revealed confusion about the process for entering and verifying new medication orders, with several staff members unsure of their responsibilities or the accuracy of the orders entered into the EHR. Further, the nurse practitioner and other staff reported that the medication list in the EHR did not match the hospital discharge orders, and it took several days to identify and attempt to correct the discrepancies. During this period, the resident was not receiving all prescribed medications, and staff did not consistently document or clarify missing or incorrect orders. The lack of timely and accurate medication reconciliation and administration directly contravened facility policy and resulted in the resident not receiving necessary pharmaceutical care as ordered.
Failure to Enforce Smoking Policy in LTC Facility
Penalty
Summary
The facility failed to ensure an environment as free of accident hazards as possible by not adhering to its smoking policy. The policy mandates that all smoking materials be kept at the nurses' stations and that residents should not retain smoking materials or lighters in their rooms. However, several residents were found to have smoking supplies on their person and in their rooms, contrary to the facility's policy. This was observed during interviews and inspections, where residents were seen with cigarettes and lighters in their possession and in their rooms. Resident #27, who was diagnosed with chronic obstructive pulmonary disease (COPD) and other health issues, was found to have cigarettes and lighters in his/her room and on his/her person. Despite being assessed as a safe smoker, the resident was not following the facility's policy of keeping smoking materials at the nurses' station. Similarly, Resident #268, who had a history of COPD and other conditions, was not care planned for smoking, and there was no documentation of a smoking assessment. This resident also kept smoking supplies in his/her room and smoked unsupervised. Other residents, such as Resident #49 and Resident #67, were also found to have smoking materials in their rooms and on their person, despite being care planned to store these items at the nurses' station. Interviews with staff, including a CNA and an RN, revealed that residents often carried their own smoking supplies and smoked unsupervised, which was against the facility's policy. The Director of Nursing and the Administrator were unaware of these practices, indicating a lack of enforcement and oversight of the smoking policy.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was palatable and at a safe and appetizing temperature. The facility's policy, as outlined in the Nutrition and Dining Services Manual, requires hot foods to be served at a minimum of 120 degrees Fahrenheit. However, multiple residents reported that their meals were often cold, with specific complaints about cold eggs and low-quality meat. During a resident council meeting, several residents expressed dissatisfaction with the temperature and quality of their meals, indicating that the food was often barely warm or cold. Observations of meal trays confirmed these complaints, with recorded temperatures for various food items falling below the required 120 degrees Fahrenheit. For instance, scrambled eggs were measured at 97.1 degrees Fahrenheit, and a sausage patty at 85.9 degrees Fahrenheit. Additionally, the food was described as bland and unappetizing. Interviews with staff revealed that while tray audits were conducted when complaints were made, the issues with food temperature and quality persisted. The Dietary Manager acknowledged that residents were not satisfied with certain meals, and the Administrator expected staff to adhere to the facility's food service policy.
Improper Dish Drying Practices Lead to Potential Contamination
Penalty
Summary
The facility failed to adhere to proper food safety protocols by not allowing dishes to air dry before stacking them, which could lead to potential contamination or bacterial growth. Observations on multiple occasions revealed that a significant number of plastic bowls, dessert cups, ceramic plates, serving trays, plate covers, and metal steam table pans were stacked upside down while still wet, trapping water droplets and preventing adequate air flow. This practice was contrary to the facility's policy and the 1999 Food Code issued by the FDA, which mandates that equipment and utensils must be air-dried before being stacked or stored. Interviews with dietary staff, including a Dietary Aide, a staff member identified as [NAME] T, and the Dietary Manager, confirmed that dishes should be air-dried before being put away. The Dietary Manager specifically noted that dishes should not be stacked wet due to the risk of bacterial growth. The facility's Administrator also expressed an expectation that staff follow the food service policy, which includes allowing dishes to air dry before stacking. Despite these expectations and policies, the facility's practices did not align with the required standards, leading to the identified deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by multiple deficiencies observed during the survey. The facility did not adhere to its own policy and standards of practice regarding tuberculosis (TB) screening for new hires. Three staff members, including a CNA, an LPN, and a Dietary Aide, did not receive the two-step tuberculin skin test within the required timeframe. The initial TB tests for these staff members were either delayed or not read within the 48 to 72-hour window, and the second step was not administered according to the recommended schedule. Additionally, the facility failed to maintain catheters in a manner that prevents bacterial contamination. Observations revealed that a resident's catheter bag and tubing were repeatedly found on the ground, potentially introducing bacteria into the system. Staff interviews confirmed that catheter bags and tubing should not be dragging on the floor, yet this practice was not consistently followed. The facility also demonstrated lapses in medication administration and hand hygiene practices. Staff were observed touching medications and the inside of medication cups with bare hands, potentially contaminating the medications. Hand hygiene was not consistently performed during incontinent care or wound care, increasing the risk of cross-contamination. Furthermore, shared medical equipment, such as glucometers, was not properly sanitized between uses, contrary to the facility's policy and manufacturer recommendations.
Failure to Complete PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with diagnoses of paranoid schizophrenia and major depressive disorder prior to or upon admission. The resident was admitted with a diagnosis that necessitated a PASARR, but the facility did not have documentation of a completed PASARR in the resident's medical record. The Business Office Manager was unable to locate the level one PASARR documentation, and the Social Services Director indicated that they attempt to complete these forms within 48 hours of admission. The resident's care plan included interventions for managing delusions, such as redirecting the resident and administering medication as per physician orders. However, the absence of a PASARR indicates a failure to ensure the resident received appropriate care and services tailored to their mental health needs. The Administrator mentioned that the PASARR was done in 2007 before electronic records, and staff should verify the presence of a DA 124 form upon admission if required by the resident's diagnosis.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistency in a resident's code status across their medical records, leading to a deficiency. The resident, who had a history of cerebral infarction, Parkinson's disease, cognitive communication deficit, and Type 2 diabetes mellitus, had chosen a Do Not Resuscitate (DNR) status. However, discrepancies were found in the documentation: the resident's face sheet and care plan indicated a DNR status, while the physician's order sheet listed the resident as a full code. This inconsistency was observed despite the resident having signed an Outside the Hospital Do Not Resuscitate (OHDNR) form, which was also signed by the physician. Interviews with various staff members, including CNAs, CMTs, LPNs, and the Director of Nursing, revealed that the code status should be consistent across all documentation, including the resident's door, care plan, and electronic medical records. However, the inconsistency persisted, as evidenced by the red dot on the resident's door indicating a DNR status, while the physician's order contradicted this. The staff, including the Assistant Director of Nursing and the Administrator, acknowledged that the code status should be uniform throughout the resident's chart, highlighting a failure in maintaining accurate and consistent documentation of the resident's wishes.
Failure to Document and Treat Resident's Elbow Wound
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the management of a wound on the resident's left elbow. The resident, who had a history of osteomyelitis and MRSA, experienced an elbow wound that was not consistently documented or treated according to physician orders. The facility's staff did not maintain current lists of orders in the resident's clinical record, leading to confusion and errors in treatment. Additionally, there was a lack of documentation regarding the notification of the physician and assessments of the wound. The resident's medical records showed multiple instances where staff failed to document the assessment or treatment of the elbow wound. Despite the resident's complaints of pain and the presence of drainage, there were no documented orders for treatment of the wound from early November through mid-December. The visiting wound clinic's notes indicated that the wound had worsened over time, with increased drainage and the presence of bone fragments. However, the facility staff did not consistently document these findings or follow up with appropriate treatment orders. Interviews with facility staff revealed a lack of communication and coordination among the various healthcare providers involved in the resident's care. The Assistant Director of Nursing (ADON) and other staff members acknowledged the documentation issues and the challenges posed by the involvement of multiple physicians. Despite the resident's requests for a wound culture and concerns about the worsening condition, the facility did not adequately address these issues, leading to a deficiency in the standard of care provided to the resident.
Inadequate Documentation of Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice. The resident, who was admitted with an unspecified open wound on the right hip, had a care plan indicating the presence of a pressure ulcer. However, the facility did not document regular full wound assessments as required. The resident's medical records showed gaps in documentation, with no assessments or measurements recorded for extended periods, despite the presence of a wound management log and physician orders for treatment. Interviews with staff revealed inconsistencies in the wound assessment and documentation process. The Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) indicated that wound assessments and measurements were not consistently performed or documented unless conducted by a visiting wound clinic. The ADON acknowledged that documentation was an issue, and the Director of Nursing (DON) stated that wound monitoring should be completed weekly and documented in the nurses' notes. The resident expressed that staff did not assess the wound on a weekly basis, and the facility's policy required documentation of skin assessments, including any abnormalities. Despite the policy and the resident's care plan, the facility did not maintain consistent documentation of the wound's condition, leading to a deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Medication Unavailability for Residents
Penalty
Summary
The facility failed to provide pharmacy services to meet the needs of each resident, as evidenced by the unavailability of ordered medications for two residents. Resident #49, who was admitted with a diagnosis of vitamin B12 deficiency, did not receive the prescribed B Complex-Vitamin B12 tablets for a significant portion of November and all of December. The Medication Administration Record (MAR) indicated that the medication was unavailable for 18 out of 30 doses in November and all 13 doses in December. The resident confirmed during an interview that there were times when medications were not available, and the Assistant Director of Nursing (ADON) was unaware of the issue until it was brought to her attention. Resident #13, who was admitted with diagnoses including constipation and pain, also experienced medication unavailability. The resident's MAR showed that Senna Plus, a laxative, was not administered for several days in December due to unavailability. Additionally, acetaminophen, prescribed for pain management, was not administered for multiple doses. Interviews with staff, including Certified Medication Technicians (CMTs) and Licensed Practical Nurses (LPNs), revealed that there was a lack of communication and follow-up regarding the unavailability of medications, and the staff did not consistently notify the appropriate personnel to address the issue. The facility's policy on medication administration requires that medications be given as ordered by the physician. However, the report highlights a breakdown in the process, as staff failed to ensure that medications were available and administered as prescribed. Interviews with the Director of Nursing (DON) and the Administrator confirmed that staff should follow procedures for medication administration and notify the appropriate personnel if medications are unavailable. Despite these expectations, the residents went without their prescribed medications for extended periods, indicating a deficiency in the facility's pharmacy services.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 12.5 percent error rate. This was due to four medication errors out of 32 opportunities, affecting two residents. For one resident, the Certified Medication Tech (CMT) administered incorrect doses of Vitamin D3 and failed to provide acetaminophen and Senna Plus due to unavailability. The CMT acknowledged the absence of these medications and had informed the Assistant Director of Nursing (ADON) about the supply issue. Interviews with staff revealed a lack of adherence to procedures for checking emergency kits and notifying physicians when medications were unavailable. Another deficiency involved the administration of insulin to a resident. The Licensed Practical Nurse (LPN) administered fast-acting insulin without ensuring the resident received a meal within the recommended time frame. The resident did not receive a meal until 54 minutes after insulin administration, contrary to best practices that suggest a meal or snack should be provided within 30 minutes. Interviews with staff, including the ADON and Director of Nursing (DON), confirmed the expectation that meals should be provided promptly after insulin administration. The facility's policy on medication administration lacked specific guidance on insulin administration timing, contributing to the deficiency. Staff interviews highlighted inconsistencies in following procedures for medication administration and communication regarding unavailable medications. The Director of Nursing and Administrator emphasized the importance of adhering to physician orders and ensuring residents do not go without necessary medications.
Failure to Provide Timely Meal After Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of rapid-acting insulin. Resident #42, who has diagnoses including chronic kidney disease, high blood pressure, diabetes, and weakness, was administered six units of insulin aspart subcutaneously at 11:21 A.M. However, the resident was not provided with a meal or snack within the recommended time frame after insulin administration. Observations showed that the resident had not received a lunch tray 54 minutes after the insulin was given, and there were no snacks visible in the resident's room. Interviews with staff, including LPNs, CMTs, the ADON, and the DON, revealed inconsistencies in the understanding and implementation of insulin administration protocols. While some staff members indicated that a meal or snack should be provided within 30 minutes of insulin administration, others suggested that waiting up to an hour might be acceptable, though not best practice. The facility's policy on medication administration did not provide specific guidance on the timing of meals or snacks in relation to insulin administration, contributing to the deficiency observed.
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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