Butler Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Butler, Missouri.
- Location
- 416 S High Street, Butler, Missouri 64730
- CMS Provider Number
- 265275
- Inspections on file
- 15
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Butler Rehab And Healthcare Center during CMS and state inspections, most recent first.
Kitchen sanitation deficiencies were observed during meal prep, including food debris on the can opener blade, debris under the 6-burner stove, dust on vent fans and a sprinkler head in the walk-in refrigerator, and dust and grease on light fixtures and ceiling vents. The Dietary Mgr stated the area under the stove may not have been cleaned for two weekend nights and that maintenance was expected to clean the refrigerator sprinkler head and fans.
A facility failed to keep resident rooms, shared restrooms, baths, dining areas, fans, vents, and a tube feeding pole clean and in good repair. Surveyors observed heavy dust in ceiling vents, grime and debris on floors, damaged and peeling flooring, dusty personal fans, and residue on a tube feeding pole base. Staff interviews showed housekeeping coverage gaps, limited cleaning tools, and uncertainty about who was responsible for cleaning certain items.
A facility failed to follow infection control practices during care for three residents. An LPN did not use gown-based EBP, used a barrier improperly for IV/PICC supplies, and handled a dropped alcohol wipe during IV medication administration for a resident on EBP. During insulin administration for a resident with diabetes, an LPN removed gloves and put on new ones without hand hygiene. A CMT also used a shared BP cuff without cleaning it before and after use during medication pass.
A resident with multiple chronic conditions, including stroke, dysphagia, CHF, AFib, CKD, and COPD, was assessed by the IDT as not safe to self-administer medications and was supposed to have all meds remain with staff. Surveyors nevertheless found an expired Vitamin D3 bottle with unidentified pills, an open bag of cough drops, and a cup of medications on the bedside table. The resident said the pills were taken daily and that the meds had been given that morning, while a CMT said he/she was unaware of any meds kept in the room and did not know where to find the self-administration assessment.
Failure to submit TPL form after resident death. A resident died with $8.68 remaining in the resident trust account, but review of trust fund records showed no TPL was submitted to MO HealthNet within the required 30-day timeframe. The BOM stated the form was not submitted because he/she believed the guardian was responsible for filing it.
Failure to Follow Criminal Background Check Policy: The facility did not follow its abuse prevention policy for criminal background checks for two employees. One employee’s background check was not obtained until well after hire, and another re-hired CNA’s background check was not re-run. The HR Director stated the original background check could not be found for one employee and that the prior HR Director did not re-run the check for the CNA.
A resident with dementia, confusion, and supervision needs fell from a chair and sustained a minor head abrasion, but the fall investigation was incomplete. The record did not fully document the circumstances of the unwitnessed fall, contributing factors, or a detailed injury description, and it did not show notification of the resident’s family or emergency contact despite the resident’s impaired decision-making capacity. Staff and the DON acknowledged that the incident report should have been comprehensive, but key elements were missing.
A resident with a colostomy, urostomy, paraplegia, and bladder dysfunction was providing most of his/her own ostomy care, but the chart lacked a physician order authorizing self-care and lacked a documented nursing self-care assessment. The care plan did not reflect the resident’s ability to manage the ostomies, even though staff and the resident stated he/she was doing the care with standby assistance and the DON, LPN, ADON, and ICP acknowledged the missing documentation.
A resident with a PEG tube, dysphagia, and severe cognitive impairment had a physician order for Fiber Source HN 1.2 at 47 ml/hr, but observations showed Diabetisource AC 1.2 was being run instead. The care plan noted tube feeding was needed but did not include the prescribed formula. Nursing documentation did not identify the formula being administered, and an LPN confirmed the formula in use did not match the order.
Uncovered oxygen equipment and tubing were observed for two residents. One resident with COPD, respiratory failure, and other respiratory conditions had CPAP and breathing treatment masks and tubing left uncovered on the dresser beside the machines while using continuous O2. Another resident with COPD and smoking history had nasal cannula tubing on the floor under clothing, not bagged, with dated tubing and an undated water container. Staff stated oxygen equipment should be bagged and kept off the floor when not in use.
A cold cottage cheese fruit plate was placed on room tray carts and left there without being returned to refrigeration, then delivered to residents on the 100 Hall at 52.1 F instead of at or near 41 F. The recipe identified 41 F as the CCP for service, and the Dietary Mgr said the plates likely warmed because they were on the same cart with hot foods and temperatures were not checked that day.
The facility failed to ensure pureed chicken was prepared to a smooth consistency for two residents on pureed diets. The DM made the chicken without adding thickener, did not have the recipe open during preparation, and did not taste it before serving. The surveyor found the pureed chicken was grainy, and the DM later acknowledged it was grainier than it should have been.
A resident with diabetes and traumatic brain injury, who wished to remain in LTC, was discharged to a homeless shelter after being sent to the hospital, with immediate discharge paperwork citing behavioral concerns. The discharge process lacked proper documentation, the resident's signature, and staff clarity on appropriate procedures.
A contracted PTA did not adequately explain therapy procedures or obtain informed consent before providing treatments to several residents, resulting in confusion and discomfort. Multiple residents with various medical conditions reported that the PTA initiated physical contact, including touching near the chest and abdomen, without prior explanation, causing them to feel uneasy or distressed. Interviews confirmed that proper communication protocols were not followed, leading to a deficiency in upholding residents' rights.
The facility failed to update care plans for several residents, including those with pressure ulcers, smoking supervision needs, and pain management. Observations and interviews revealed inconsistencies and lapses in accurately reflecting residents' current conditions and needs.
The facility failed to ensure proper TB screening for both residents and new employees. Four residents did not receive timely or documented TB tests, and two new employees started working without completing the required TB tests. Interviews revealed systemic issues in the administration and documentation of TB tests.
The facility failed to provide the required 12 hours of training and in-services, including behavior and dementia training, abuse and neglect prevention, and resident rights, for three CNAs. Despite attending various in-services, the specific required topics were not covered, and the total training hours did not meet the mandated 12 hours from April 2023 to April 2024.
The facility failed to develop a spend-down plan for two residents who maintained balances exceeding the Missouri Medicaid limit in their Resident Trust Fund accounts for more than one month. The Business Office Manager informed the residents of their excess balances but did not assist in creating a plan to manage the funds, risking the loss of Medicaid benefits.
The facility failed to accurately document a resident's advance directives, resulting in conflicting Full Code and DNR orders in the care plan. Interviews with staff revealed inconsistencies in updating and verifying the resident's code status, despite the resident's guardian providing verbal consent for Full Code.
The facility failed to follow its policy to conduct CBC and check the NA Registry for new employees before hiring. Employee B started work without a completed NA registry check, and Employee F's NA registry check was completed two days after their hire date. The BOM/HR and DON confirmed that these checks should be completed before new employees start working.
A resident with a history of cerebral infarction and hemiplegia did not receive necessary ROM treatment and services, including a previously ordered splint and therapy. The resident's left hand was observed to be contracted without any devices to maintain a neutral position, and interviews with staff confirmed the lack of appropriate interventions.
The facility failed to ensure that a physician reviewed and acted upon a pharmacist's monthly Drug Regimen Review (DRR) recommendations for a resident with a complex medical history. Despite the pharmacist identifying irregularities and making recommendations, no physician responses were found in the resident's medical record for two months, and a critical recommendation was not fully addressed in a third month.
The facility failed to ensure that two residents received necessary dental services for broken teeth. Both residents had significant dental issues, including missing and broken teeth, and expressed a desire to see a dentist. However, no dental appointments were made, and their care plans did not reflect any dental concerns. Staff interviews revealed systemic issues in handling dental care, including inadequate documentation and lack of follow-up.
Kitchen Sanitation Deficiencies
Penalty
Summary
The kitchen failed to maintain sanitary food service conditions during survey observation, with food debris found on the blade of the table top can opener, food particles and debris accumulated under the 6-burner stove, dust buildup on the vent fans and sprinkler head in the walk-in refrigerator, dust and grease on light fixtures, and dust inside the ceiling vents in the kitchen. During the lunch meal preparation observation, surveyors noted these conditions in multiple food preparation and storage areas, including over the microwave and dish storage area next to the reach-in refrigerator. In interview, the Dietary Manager stated dietary staff should clean the debris from under the stove every night, said the area under the 6-burner stove had probably not been cleaned for the two weekend nights before survey, and stated the dust on the light fixtures was related to the lack of a regular maintenance person. The Dietary Manager also said maintenance was expected to clean the sprinkler head and fans in the walk-in refrigerator because those tasks were beyond dietary staff duties.
Failure to Maintain Clean and Safe Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by allowing dust, debris, grime, and damaged flooring to remain in multiple resident areas and common spaces. Survey observations found heavy dust buildup in ceiling vents in the dining room, the 300 Hall Central bath, the 100 Hall Central Bath, the 200 Hall Central bath, shared restrooms between resident rooms 308 and 310 and between 306 and 304, and in resident room vents. Floors were observed with peeling, torn, or damaged surfaces in the shared restroom of resident rooms, the 300 Hall Central Bath, and restrooms in resident rooms, and floors in resident rooms 313, 307, 304, 302, 305, 303, 300, 111, 105, 106, and 102 were observed with grime, dust, hair, and debris. Personal fans in resident rooms 300, 303, 103, and 107 had heavy dust buildup, and the base of a tube feeding pole in a resident room had brown-colored substance on it. During interviews, the Housekeeping Supervisor said he/she had been away from duties for several months and that no one stepped up to serve in that role during the absence. The Housekeeping Supervisor stated that floors were expected to be mopped and swept daily, that personal fans had not really been cleaned since the former maintenance person left, and that the former maintenance person used to clean ceiling vents but no one was currently doing so. A housekeeper said scrapers were not available to remove grime from floors and that he/she did not want to move beds to clean under them if residents were sleeping. Another housekeeper said the damaged floor in the shared restroom of resident rooms had been like that for several months and that the restroom floor in a resident room was difficult to clean because of the damage. An LPN said he/she would have to find out who cleaned the tube feeding pole and did not clean it, while the ADON stated that housekeepers were responsible for cleaning the tube feeding pole.
Failure to Follow EBP, Hand Hygiene, and Equipment Cleaning Procedures
Penalty
Summary
The facility failed to ensure hand hygiene and Enhanced Barrier Precautions (EBP) for a resident with a physician’s order for EBP, and the facility policy did not include instructions for nursing staff to wear gowns with EBP or to use EBP for residents with indwelling devices. Resident #47 had diagnoses including MRSA carrier status and had orders for EBP related to an indwelling catheter and PICC line, along with daily IV ertapenem for a UTI. During observation, an LPN entered the room without a gown, placed IV medication and supplies on the resident’s overbed table without a barrier, handled the resident’s PICC line and IV medication, left the room to seek help mixing the medication, returned, and continued the IV administration without using a gown. The LPN also picked up an alcohol wipe package from the floor and used it on the resident’s PICC line. The DON stated the resident was on EBP, gowns should have been worn for IV medication administration and PICC line care, barriers should have been used for supplies, and the dropped alcohol wipe should have been discarded. The facility also failed to ensure hand hygiene between glove changes during insulin administration for a cognitively intact resident with diabetes who received insulin seven days per week. During observation, an LPN performed blood glucose testing and then returned to the medication cart with the same gloves, removed the gloves, and put on a new pair without performing hand hygiene before cleaning the glucometer and preparing to give insulin. The LPN stated he or she had not realized hand hygiene was missed between glove changes and said it should have been done before giving insulin. Another LPN and the DON stated staff should perform hand hygiene between glove changes and that staff received regular hand hygiene training. The facility further failed to ensure shared medical equipment was cleaned before and after use for a resident who required blood pressure monitoring before receiving antihypertensive medications. The resident had diagnoses including dementia, atrial fibrillation, hypertension, and heart failure. During medication pass, a CMT performed hand hygiene, entered the resident’s room, used a blood pressure cuff without sanitizing it first, obtained the blood pressure, administered medications, and did not sanitize the cuff after use. The CMT stated the cuff was used on multiple residents during medication pass and should have been cleaned before and after each use. The DON stated shared medical equipment should be cleaned before and after use.
Unsupervised Medications Left at Bedside Despite No Self-Administration Approval
Penalty
Summary
The facility failed to ensure that only residents assessed and determined safe by the interdisciplinary team (IDT) could self-administer medications, and it failed to ensure medications were not left unattended for a resident who had been assessed as unable to self-administer. The cited resident had multiple diagnoses including cerebral infarction, dysphagia, congestive heart failure, atrial fibrillation, pulmonary hypertension, chronic kidney disease, and COPD. The resident’s quarterly MDS showed the resident was cognitively intact and able to understand others and make needs known. The resident’s Medication Self-Administration Safety Screen showed the resident was assessed for self-administration of all medications and was determined to require assistance with reading labels, identifying medications, stating what each medication was for, stating the time/frequency, and stating the correct dosage and quantity. The assessment indicated all medications were to remain with staff and that the IDT determined it was not safe for the resident to self-administer any medications. The resident’s physician order sheet and MAR listed multiple scheduled medications, and there was no physician order for self-administration or for keeping medications at bedside. Despite this, surveyors observed an expired Vitamin D3 bottle with unidentified pills in it on the resident’s bedside table, an open bag of cough drops on the bedside table, and a small plastic cup filled with medications on the bedside table. During interviews, the resident stated the pills were for strength and that he/she administered them daily, and also stated the medications had been given that morning but he/she was not ready to take them yet. A CMT stated he/she gave the resident all morning medications and watched them be swallowed, but was not aware of any medications kept in the room or where to find the self-administration assessment. The DON stated residents determined ineligible for self-administration should not have medications left with them or kept at bedside, and that staff should ensure all medications were taken and swallowed before leaving the room.
Failure to Submit TPL Form After Resident Death
Penalty
Summary
The facility failed to submit a Third Party Liability (TPL) form to Missouri HealthNet within 30 days after the death of one resident. Resident #11 died with a resident trust account balance of $8.68, and review of the trust fund records 49 days after the death showed that no TPL had been submitted within the required timeframe. During interview, the Business Office Manager stated that the TPL was not submitted because he/she believed the guardian was responsible for submitting the TPL forms.
Failure to Follow Criminal Background Check Policy
Penalty
Summary
The facility failed to follow its Abuse and Neglect policy and procedure for checking criminal background information for two sampled employees, Maintenance Worker A and CNA C, out of 10 sampled employees. The policy stated the facility maintains a zero-tolerance program for abuse, neglect, mistreatment, and misappropriation of resident property, and that it does not knowingly employ anyone with certain abuse-related findings or convictions. The facility census was 59 residents. Maintenance Worker A’s record showed a hire date of 7/1/23, but the criminal background check was not requested until 8/19/24 and was received the same day. CNA C’s record showed a hire date of 1/6/25, but the criminal background check was requested on 9/18/24 and received the same day. During interview, the Human Resources Director stated Maintenance Worker A was not a re-hire and that the original criminal background check could not be found. The Human Resources Director also stated CNA C was rehired on 1/6/25 and the former Human Resource Director did not re-run the background check as required.
Incomplete Fall Investigation and Notification Documentation
Penalty
Summary
The facility failed to complete a comprehensive investigation after a resident fell from a chair and sustained a minor injury. The resident had multiple diagnoses including heart failure, depression, anxiety, arthritis, auditory and visual hallucinations, dementia, and muscle weakness. The resident’s MDS showed significant cognitive incapacity and need for supervision with transfers and mobility, and the care plan identified the resident as being at risk for falls related to confusion. According to the nursing notes and incident report, the resident was found lying face down on the floor after an unwitnessed fall from a chair while asleep and leaning forward. The resident had an abrasion to the forehead and bridge of the nose, and staff assisted the resident back into the chair using a gait belt. The documentation did not consistently describe the circumstances of the fall, including where the resident was located, when the resident was last seen, what the resident was doing immediately before the fall, or a detailed description of the abrasion. The incident report also did not identify contributing environmental, physiological, or situational factors, and it did not show that the resident was not wearing grips on the socks. The record also did not show notification of the resident’s family or emergency contact after the fall, despite the resident’s confusion and inability to make decisions independently. Staff documented the resident as his or her own responsible party, while the DON stated the resident had a BIMS of 3 and was not believed to be able to make his or her own decisions. The facility’s fall documentation was incomplete in that it did not include a comprehensive risk analysis of what occurred and did not clearly document all required notifications and investigation details.
Missing Order and Care Plan for Self-Performed Ostomy Care
Penalty
Summary
The facility failed to obtain a physician’s order and failed to update the care plan for a resident with a colostomy and urostomy who was providing his/her own ostomy care. The resident was admitted with paraplegia, colostomy status, neuromuscular dysfunction of the bladder, and artificial opening of the urinary tract status. The resident’s nursing self-medication assessment stated the resident could not self-administer medication and required nursing staff to administer medications, and there was no nursing assessment in the record to evaluate the resident’s ability and knowledge to provide own self-care for the colostomy and urostomy. The resident’s care plan addressed ADL self-care deficits related to paraplegia, but it did not include the resident’s ability to provide own self-care for the colostomy or urostomy. The physician order sheet and TAR contained orders for nursing to provide and change the urostomy and colostomy appliances, monitor the stomas, and change bags as needed, but there was no physician’s order allowing the resident to provide own ostomy care or to assist with ostomy care. The record also did not contain a documented self-care assessment for ostomy care, despite staff stating the resident had been providing most of his/her own ostomy care with standby assistance. During interviews, the resident stated he/she provided his/her own colostomy and urostomy care and had shown staff how to change the bags. The DON, LPN, ADON, and ICP acknowledged that the resident had been providing his/her own ostomy care, that there was no physician’s order for self-care, and that a self-care assessment should have been completed and documented. Observation showed the resident’s urostomy and colostomy sites were pink with no redness or signs of infection, and the resident reported no concerns with ostomy care.
Incorrect Tube Feeding Formula and Incomplete Care Plan Documentation
Penalty
Summary
The facility failed to ensure the physician-ordered enteral supplemental tube feeding formula was followed for one resident with a gastrostomy tube and failed to update the resident’s care plan to include the prescribed tube feeding formula. The resident was admitted with gastrostomy status and dysphagia, was severely cognitively impaired, and required supplemental tube feeding for nutritional intake. The care plan documented the need for tube feeding, but it did not identify the type of formula prescribed by the physician or registered dietitian. The resident’s physician order sheet listed Fiber Source HN 1.2 via PEG tube at 47 ml/hour continuously for 22 hours, with a possible two-hour break in 24 hours for activities and care. The treatment administration record also reflected Fiber Source HN 1.2. However, during observation, the resident’s tube feeding pump was running with Diabetisource AC 1.2 cal instead of the ordered formula, and the bag was labeled with handwritten dates. Nursing documentation noted the resident remained NPO with continuous PEG-tube feedings, but did not identify the formula being administered. On a later observation, Diabetisource AC was again connected and running at 47 ml/hour, even though Fiber Source HN 1.2 had been transcribed to the physician order sheet. During medication administration via the PEG tube, the LPN placed the tube feeding on hold, disconnected it, and then reconnected the Diabetisource AC after medications were given. The LPN stated the physician order showed Fiber Source HN and not Diabetisource AC. The DON stated staff were expected to check the physician order and double-check before connecting the tube feeding, and also stated the resident’s care plan had been reviewed and updated during IDT meetings.
Uncovered oxygen equipment and tubing
Penalty
Summary
The facility failed to ensure respiratory face masks and tubing were covered to prevent cross contamination when not in use for two residents. The facility policy stated that oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen were for single resident use only and were to be stored in a plastic bag at the resident’s bedside when not in use. One resident had diagnoses that included COPD, heart disease, respiratory failure, chronic cough, and rhinitis, and was dependent on staff for multiple activities of daily living and used oxygen. The resident’s record showed continuous oxygen at 2 liters, daily humidifier checks, and CPAP use for COPD. During observations, the resident was in bed or sitting up with oxygen in place, while the CPAP machine and breathing treatment machine were on the dresser with the face masks and tubing uncovered and lying on top of or beside the machines. The resident stated that the breathing treatment machine was used during the day and the CPAP machine at night, and staff assisted with both machines. The second resident had COPD, nicotine dependence, smoked, and received oxygen therapy. The resident’s record included orders for oxygen via nasal cannula as needed and weekly disposal of oxygen tubing, humidifier, and plastic bag if present. During three observations, the nasal cannula and tubing connected to the oxygen concentrator were on the floor under clothing items, were not bagged, and were dated 2/6/26; the water container was not dated. Staff interviews confirmed that oxygen tubing, cannulas, masks, and water containers should be changed weekly, dated, and kept off the floor and bagged when not in use, and the DON stated nursing staff were responsible for ensuring this was done.
Cold Food Served Above Safe Temperature
Penalty
Summary
The facility failed to ensure a cold dish, cottage cheese fruit plate, was served at a temperature at or close to 41 F to three residents who received room trays on the 100 Hall. The recipe for the dish identified a critical control point to hold the food for service at 41 F or lower, and the preparation instructions stated that ingredients should be returned to refrigerator storage if preparation was interrupted. On 2/23/25 at 11:53 A.M., a Dietary Aide placed bowls of cottage cheese fruit plate on room tray carts. From 11:53 A.M. to 12:19 P.M., the plates remained on the cart without being returned to refrigeration. The room trays arrived on the 100 Hall at 12:20 P.M., and a CNA delivered trays to the 100 and 200 Halls from 12:21 P.M. to 12:30 P.M. At 12:31 P.M., in the presence of the DON and CNA, the temperature of the cottage cheese fruit plate was measured at 52.1 F. During interview, the Dietary Manager stated there were times temperatures of room trays were checked, but he/she could not check them that day because he/she was the cook and did not have time, and said the cottage cheese fruit plates probably got warmer because they were on the same cart with the hot foods.
Pureed Chicken Was Served With an Improper Texture
Penalty
Summary
The facility failed to ensure that pureed chicken tenders were prepared in a smooth consistency for residents on pureed diets. The undated recipe for pureed baked chicken called for baked chicken, chicken base with water, and commercial thickener. During observation, the Dietary Manager made pureed chicken and added broth but did not add thickener, and there was no recipe book open while the food was being prepared. After the chicken was placed in a pan, the Dietary Manager did not taste it. The state surveyor later tasted the pureed chicken and found that it was grainy rather than smooth, although it was flavorful. When the Dietary Manager tasted it after being asked by the surveyor, he/she acknowledged that it was grainier than it should have been and stated that if it had been tasted the first time, the texture problem would have been identified.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was sent to the hospital and subsequently discharged with paperwork indicating a return to a homeless shelter. The resident, who was cognitively intact and had a history of diabetes and traumatic brain injury, had expressed a desire to remain in long-term care according to their care plan. Despite this, the discharge paperwork listed a homeless shelter as the destination, and the discharge was marked as immediate due to the resident being considered a danger to self and others, with the notice lacking the resident's signature. Interviews with facility staff revealed a lack of clarity and documentation regarding the discharge process. The Social Services Director stated the resident did not request discharge, and the DON was unaware if the discharge packet was completed or if discharging to a homeless shelter was appropriate. The Administrator confirmed that the resident was told not to return to the facility and that the discharge was considered immediate, citing behavioral concerns such as inappropriate comments and alcohol use. However, there was no documentation of significant behavioral incidents in the medical record, aside from a single report of inappropriate comments. The facility was unable to provide a discharge policy when requested, and staff interviews indicated uncertainty about proper discharge procedures and documentation. The discharge notice was delivered to the hospital along with the resident's belongings, but the process lacked clear documentation and did not include the resident's agreement or signature. The actions taken did not align with the resident's expressed wishes or ensure a safe and appropriate discharge destination.
Failure to Inform Residents of Therapy Procedures Leads to Discomfort
Penalty
Summary
Contracted Physical Therapy Assistant (PTA) A failed to adhere to residents' rights by not adequately informing residents about the care and treatments being provided prior to initiating therapy sessions. Multiple residents reported that PTA A did not explain the procedures or the reasons for physical contact during therapy, such as muscle palpation or massage-like actions. This lack of communication led to confusion and discomfort among several residents, some of whom were unfamiliar with therapy or had not previously received such treatments from PTA A. The deficiency involved seven residents, most of whom were cognitively intact and had various medical conditions including post-surgical weakness, stroke, muscle wasting, and spondylosis. Residents described instances where PTA A entered their rooms, began therapy or massage-like activities without prior explanation, and in some cases, touched areas near the chest or abdomen. While no residents reported pain or physical injury, several expressed feeling uncomfortable, nervous, or "creepy" after the interactions. Some residents did not immediately report the incidents, only disclosing their discomfort when later questioned by facility staff. Interviews with facility staff and the contract therapy agency director confirmed that proper protocol required PTA A to explain all procedures and obtain informed consent before touching residents, especially in sensitive areas. The director acknowledged that certain therapy techniques might require contact with the chest or inner thigh, but emphasized the necessity of clear communication to prevent misunderstanding. The lack of explanation and failure to ensure residents understood the nature of the therapy led to the deficiency, as residents' rights to be informed and to refuse care were not upheld.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for several residents were updated to reflect their current medical conditions and needs. Resident #29's care plan did not include information about an unstageable pressure ulcer, despite the resident having a physician's order for wound care treatment and a documented risk for pressure ulcers. The MDS Coordinator confirmed that the resident should have had a care plan for any type of wound, indicating a lapse in updating the care plan to reflect the resident's current condition. Resident #18's care plan was not updated to reflect the resident's need for assistance and supervision while smoking. Despite assessments indicating the resident required supervision, observations showed the resident smoking without proper assistance, leading to unsafe situations where other residents had to help. Interviews with staff revealed inconsistencies in the supervision and assistance provided to the resident, highlighting a failure to ensure the care plan accurately reflected the resident's needs and the facility's policies. Resident #38's care plan lacked documentation related to the resident's current pain status, including frequency, type, and location of pain, as well as non-pharmacological pain interventions. The resident had multiple orders for pain medications and reported constant pain that affected daily activities. Similarly, Resident #47's care plan did not document all pressure ulcers, missing information about a pressure ulcer on the right heel. The DON confirmed that care plans should be updated quarterly and as needed, indicating a failure in the facility's process for maintaining accurate and comprehensive care plans.
Failure to Properly Screen for Tuberculosis
Penalty
Summary
The facility failed to ensure proper screening for Tuberculosis (TB) for both residents and new employees. Four residents were not screened according to the facility's TB policy, which mandates a two-step TB test upon admission and annual testing thereafter. For instance, Resident #29 had multiple instances where TB tests were either not read or not documented, and similar issues were observed with Residents #38, #47, and #50. The Infection Preventionist (IP) and Director of Nursing (DON) acknowledged that many residents' TB tests were not done timely or documented correctly, attributing the lapses to previous staff not keeping track of the tests properly. Additionally, the facility failed to properly screen new employees for TB before they started working. Employee G and Employee J did not have their TB tests completed and documented as required. Employee G's second TB test was administered but not read, while Employee J started working before the first TB test was administered. The Assistant Director of Nursing (ADON) and the Business Office Manager (BOM)/Human Resources (HR) Director confirmed these lapses, with the ADON admitting that new employees were usually hired directly after the interview and started working once the first TB test was read with a negative result. Interviews with the IP, DON, ADON, and BOM/HR Director revealed systemic issues in the administration and documentation of TB tests for both residents and employees. The IP and DON were responsible for ensuring timely TB tests for residents, while the ADON was responsible for tracking employee TB tests. However, the lack of proper documentation and adherence to protocols led to significant deficiencies in the facility's infection prevention and control program.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required 12 hours of training and in-services, including behavior and dementia training, abuse and neglect prevention, and resident rights, for three Certified Nursing Assistants (CNA B, C, & D). The review of the training records for these CNAs showed that they did not receive the necessary training in critical areas such as abuse and neglect, behavior and dementia training, resident rights, and care of cognitively impaired residents. Despite attending various in-services, the specific required topics were not covered, and the total training hours did not meet the mandated 12 hours from April 2023 to April 2024. During an interview, the Director of Nursing (DON) confirmed that CNAs should receive 12 hours of in-service training annually, with monthly in-services covering essential topics like abuse and neglect safety, dementia and Alzheimer's safety, and other resident needs. The DON also mentioned that in-services were typically an hour long and conducted by the DON, ADON, or other department heads. However, the facility failed to provide documentation of a policy for the required training, and the Human Resource staff did not adequately monitor the in-service hours for the CNAs, including those working on a PRN basis.
Failure to Develop Spend-Down Plan for Resident Trust Funds
Penalty
Summary
The facility failed to develop a spend-down plan for two residents who maintained a balance exceeding the Missouri Medicaid limit of $5,726.00 in their Resident Trust Fund (RTF) accounts for more than one month. Resident #13's RTF balance consistently exceeded the legal limit from September 2023 to March 2024, reaching as high as $11,044.75. Similarly, Resident #18's RTF balance also remained above the legal limit during the same period, with a peak balance of $10,944.75. Despite these excessive balances, the facility did not take appropriate action to assist the residents in managing their funds to avoid losing Medicaid benefits. During an interview, the Business Office Manager (BOM) acknowledged responsibility for the RTF accounts and admitted to informing the residents that their balances were over the legal limit. However, the BOM did not inform the residents of the potential loss of Medicaid benefits due to the excess funds, nor did they assist in creating a plan to spend down the RTF money. The BOM's approach was limited to advising the residents to spend their money without providing further guidance or support, leading to the deficiency in managing the residents' funds effectively.
Failure to Accurately Document Resident's Advance Directives
Penalty
Summary
The facility failed to properly and accurately document a resident's advance directives, resulting in conflicting information regarding the resident's code status. The resident, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), chronic kidney disease, and major depressive disorder, had both a Do Not Resuscitate (DNR) order and a Full Code order documented in their care plan. This discrepancy was found during a review of the resident's electronic health record (EHR) and care plan, which showed conflicting information about the resident's wishes for life-saving measures. Interviews with facility staff, including a Certified Nurse's Assistant (CNA), a Registered Nurse (RN), the MDS coordinator, and the Director of Nursing (DON), revealed a lack of clarity and consistency in documenting and updating the resident's code status. The resident's guardian had provided verbal consent for Full Code, but the care plan still contained both Full Code and DNR orders. The MDS coordinator acknowledged the error and stated that the care plan would be revised immediately. The DON confirmed that the code status should be clearly documented and consistent across all records, and that the resident's wishes should be accurately reflected in the care plan and physician orders.
Failure to Conduct Timely Background Checks and NA Registry Checks for New Employees
Penalty
Summary
The facility failed to follow its policy to conduct Criminal Background Checks (CBC) and check the Nurses Aide (NA) Registry for new employees before hiring. Specifically, the facility did not complete a NA registry check for Employee B before their hire date and completed the NA registry check for Employee F two days after their hire date. The Business Office Manager (BOM)/Human Resources (HR) admitted that sometimes background checks slipped through the cracks, and employees were not supposed to start working until all background screenings, including NA Registry checks, were completed. Despite having a checklist to ensure all backgrounds were completed before employees started working, the facility allowed Employee B to start work immediately without completing the background process, and Employee F started working before their NA registry check was completed. During interviews, the BOM/HR and the Director of Nursing (DON) confirmed that the NA registry check should be completed before new employees start working. The BOM/HR was responsible for completing the NA registry and background checks for new hires. The facility's failure to adhere to its policy resulted in two employees starting work without the necessary background checks, which is a deficiency in the facility's hiring process and compliance with regulatory requirements.
Failure to Provide Necessary ROM Treatment and Services
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain and improve the range of motion (ROM) and mobility for a resident with significant medical conditions. The resident, who had a history of cerebral infarction, hemiplegia, and muscle weakness, was observed to have a contracted left hand without any devices or equipment to maintain a neutral hand position. Despite having an order for a left arm splint from a previous facility, the splint was never provided, and the resident did not receive any physical or occupational therapy or restorative therapies during the assessment period. Interviews with the Director of Rehabilitation (DOR) and the Director of Nursing (DON) revealed that the resident was not on therapy services and had not been evaluated or treated by the therapy department upon admission. The DOR acknowledged that the resident would have benefited from a splinting device or restorative therapies to prevent worsening of contractures. The DON confirmed that orders from the previous facility should have been reviewed and continued if appropriate, and that the resident should have received treatment to maintain or improve ROM. The lack of appropriate interventions and equipment led to the resident's continued contractures and limited mobility.
Failure to Act on Pharmacist's Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the monthly pharmacy Drug Regimen Review (DRR) recommendations for Resident #29 were reviewed and acted upon by the physician. The pharmacist's notes from 3/22/23, 4/27/23, and 9/1/23 indicated that there were irregularities and recommendations that needed to be addressed. However, no reports or physician responses were found in the resident's medical record for the notes from 3/22/23 and 4/27/23. On 9/1/23, the pharmacist recommended evaluating the necessity of two blood-thinning medications and monitoring for abnormal bleeding or bruising. Although the physician discontinued one of the medications, there was no order to monitor for abnormal bleeding or bruising as recommended by the pharmacist. The facility's policy requires that the physician respond to the pharmacist's recommendations within 30 days, but this was not done for Resident #29's DRR recommendations. Resident #29 had a medical history that included cerebral infarction, hemiplegia and hemiparesis following a stroke, bipolar disorder, anxiety disorder, and major depressive disorder. The DON confirmed that the pharmacist reviewed medications monthly and emailed the recommendations, which were then given to the physician for review and sign-off. The DON also stated that the physician should respond to the pharmacist's recommendations within 30 days and that follow-up would be done if no response was received. Despite these procedures, the facility did not ensure that the physician reviewed and acted upon the pharmacist's recommendations for Resident #29, leading to a deficiency in the resident's care.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that two residents received necessary dental services for broken teeth. Resident #25, who was admitted with moderate protein-calorie malnutrition, had most of their teeth missing or broken and had not seen a dentist since admission. Despite the resident's complaints of pain and requests to see a dentist, no dental appointments were made, and the resident's care plan did not address any dental issues. Observations confirmed the resident's poor dental condition, and interviews with staff revealed a lack of awareness and action regarding the resident's dental needs. Resident #51, admitted with a need for assistance with personal care, also had significant dental issues, including missing and broken teeth. The resident expressed a desire to see a dentist and have their teeth pulled and replaced with dentures. However, similar to Resident #25, no dental appointments were made, and the resident's care plan did not reflect any dental concerns. Staff interviews indicated that there was no proper documentation or follow-up on the resident's dental needs, and the facility's new computer system lacked a place to chart oral care or dental issues. Interviews with various staff members, including the Certified Medication Technician, Assistant Director of Nursing, Certified Nursing Assistant, Social Service Director, and Director of Nursing, highlighted systemic issues in the facility's handling of dental care. There was confusion about responsibilities, inadequate documentation, and a lack of follow-up on residents' dental needs. The facility's policy required regular dental assessments and care, but these were not consistently implemented, leading to the deficiency in providing necessary dental services to the residents.
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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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