Cedar Pointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Rolla, Missouri.
- Location
- 1800 White Columns Drive, Rolla, Missouri 65401
- CMS Provider Number
- 265279
- Inspections on file
- 20
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedar Pointe during CMS and state inspections, most recent first.
An LPN administered Lorazepam to a severely cognitively impaired resident without a physician's order, using medication from another resident's supply to calm behavioral symptoms. The medication was given for staff convenience, not as a standard treatment, and was not documented in the medical record, in violation of facility policy and residents' rights to be free from chemical restraints.
Staff did not consistently document the administration of a controlled substance for a resident with severe cognitive impairment and anxiety, and failed to complete required shiftly controlled drug counts on the memory care unit. Review of records showed missing staff signatures on multiple dates, and a discrepancy was found between the documented and observed amounts of Lorazepam. Interviews with staff and leadership confirmed that required procedures for narcotic counts and documentation were not followed.
Staff did not develop or implement comprehensive care plans for two residents with documented histories of wandering and aggression. Despite assessments, incident reports, and staff awareness of these behaviors, the care plans lacked necessary documentation and interventions to address them. The Care Plan Coordinator had not updated the plans to reflect these needs, even though staff regularly discussed resident behaviors.
An LPN at a facility misappropriated narcotic medications from three residents without authorization. The residents, who required pain management for various conditions, were affected when the LPN took their medications and failed to document them properly. The issue was discovered after the LPN exhibited suspicious behavior, leading to a positive drug test for oxycodone and subsequent arrest. Missing narcotic log sheets and medication cards were found in the trash, indicating a breach in medication management procedures.
A resident with multiple cancer diagnoses passed away in the facility, but staff failed to notify the family as required by policy. The LPN on duty admitted the oversight, and the family was informed by hospice hours later. Interviews confirmed the expectation to notify the family, doctor, and coroner, but this was not done.
The facility failed to provide adequate nursing staff as per their Facility Assessment, which required one RN or LPN per shift for each unit. From April to July, the facility consistently scheduled only one LPN for both units during night shifts. Interviews with the DON and administrator revealed they were unaware of the requirement for two licensed nurses per unit, per shift.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, as required. The RN staff schedule showed multiple days without an RN on duty, particularly on weekends. The facility is short two RN positions, with the DON and a CNA instructor covering weekday shifts. The administrator is attempting to hire additional RNs to address the shortage.
The facility failed to implement comprehensive water management policies to prevent Legionella growth and did not adhere to infection control procedures during blood glucose monitoring. An LPN placed glucometers on unsanitized surfaces without barriers, contrary to facility policy, risking pathogen transmission. The maintenance director and administrator lacked awareness of CDC Toolkit requirements and infection control protocols.
Facility staff failed to designate a qualified individual with specialized training as the Infection Preventionist for the infection prevention and control program. The ADON was identified as the Infection Preventionist but had not completed the necessary training and certification. The administrator acknowledged the requirement for certification before assuming the role, while the ADON was unaware of their designation and was still undergoing training.
Facility staff failed to update care plans for several residents following significant events, such as falls and pressure ulcers. A resident with quadriplegia and moderate cognitive impairment had a fall that was not documented in the care plan. Another resident with Alzheimer's and diabetes had a fall and a stage III pressure ulcer that were not updated in the care plan. Additionally, a resident with severe cognitive impairment and behavioral issues had an altercation that was not addressed in the care plan. Interviews revealed a lack of awareness and education among staff regarding these incidents.
The facility failed to implement its Grievance Policy for two residents who reported missing personal items. One resident reported a missing Bluetooth earbud set, and another reported a missing cell phone, but neither received updates or replacements. The grievance binder lacked documentation, and staff interviews revealed inconsistencies in the grievance process, including delays and lack of follow-up.
A resident with intact cognition and a history of falls was found with bruises on the forehead and eye area, but the facility failed to investigate and document the injuries as per policy. The CNA and NP observed the bruises but did not ensure proper documentation or notification. The DON was not informed in a timely manner, resulting in an incomplete investigation. The Administrator acknowledged the expectation for reporting and investigating such incidents, highlighting a breakdown in communication and protocol adherence.
Facility staff did not perform required neurological assessments for three residents after unwitnessed falls, as mandated by facility policy. Despite the policy requiring checks every 15 minutes for the first hour, every 30 minutes for the next two hours, and every shift for 72 hours, the medical records for these residents lacked documentation of such assessments. Interviews with an LPN and the DON confirmed the expectation for these checks, which were not completed.
Facility staff failed to properly label and store medications, with multiple undated medication bottles found on a medication cart and in a storage room. Additionally, food items were improperly stored in a medication refrigerator. Interviews with staff revealed a lack of adherence to facility policies regarding medication labeling and storage.
The facility failed to provide six residents with access to their trust fund accounts on weekends, as per their policy allowing access only on weekdays. Interviews with residents and staff revealed that residents were unable to obtain funds for weekend activities, and staff were unaware of the requirement for weekend access. All involved residents were cognitively intact, highlighting the impact of the facility's policy on their ability to manage financial affairs.
The facility failed to provide an ongoing program of activities on weekends, affecting three residents. The activity calendar showed limited scheduled activities, and interviews with residents and staff confirmed the absence of regular weekend activities. The Activities Director mentioned occasional assistance, but overall, there was a lack of coordination and communication regarding weekend activities.
Facility staff failed to protect resident privacy by leaving EHRs open and visible, contrary to HIPAA regulations. A CMT left EHRs open while administering medications, and the medication cart was unattended with visible EHRs. Interviews with the ADON and administrator confirmed staff are instructed to lock screens, but the CMT admitted to oversight.
Facility staff failed to follow professional standards in handling controlled substances, with the DON improperly destroying narcotics without a second witness and failing to document the destruction of Hydrocodone. Additionally, staff pre-prepared medications against policy, risking errors.
Facility staff failed to secure medication carts, leaving them unlocked and unattended, contrary to policy. A CMT repeatedly left a cart with keys in the lock, and a treatment cart with insulin pens was also left unsecured. Interviews confirmed the importance of locking carts to prevent unauthorized access, but staff could not explain the oversight.
Unauthorized Administration of Lorazepam as Chemical Restraint
Penalty
Summary
Facility staff failed to prevent the use of a chemical restraint on a resident when an LPN administered 0.25 ml of Lorazepam to a severely cognitively impaired resident without a physician's order or contacting the physician. The LPN took the medication from another resident's supply and gave it to the resident to calm them after they were observed yelling and keeping others awake. The LPN did not document the administration of the medication in the resident's medical record and did not follow facility policy, which requires staff to obtain a physician's order before administering medications for behaviors. The facility's policies state that residents have the right to be free from chemical restraints and that medications should not be administered for staff convenience or to control behavior unless it is a standard treatment for the resident's condition and properly ordered and documented. Interviews with the LPN, DON, and administrator confirmed that staff are not permitted to administer medications for behaviors without a physician's order and that such actions would be considered a chemical restraint.
Failure to Document Controlled Substance Administration and Complete Shiftly Drug Counts
Penalty
Summary
Facility staff failed to provide services that meet professional standards of quality by not properly documenting the administration of a controlled substance for one resident and by failing to complete required shiftly controlled drug counts on the memory care unit. Review of the facility's policy indicated that narcotics must be counted by two staff members at each shift change, with both staff initialing the count sheet and reporting discrepancies immediately. However, multiple dates were identified where the required staff signatures were missing from the controlled substance shift change forms, indicating that the counts were not consistently performed or documented as required. For one resident with severe cognitive impairment and a diagnosis of anxiety, there was a discrepancy between the documented amount of Lorazepam remaining and the amount observed in the bottle. Staff interviews confirmed that narcotic medications are supposed to be counted each shift by two nurses, and both the DON and administrator acknowledged the policy but noted that counts and documentation had not been consistently completed. The DON stated responsibility for ensuring counts but was not aware of the issue due to other responsibilities and lack of notification.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for two residents, as required by facility policy and CMS guidelines. Both residents had documented histories of wandering and physical aggression, but these behaviors were not reflected in their care plans. The care plans lacked documentation and interventions addressing these specific behaviors, despite multiple incidents and staff awareness of the residents' needs. For one resident, assessments indicated moderate cognitive impairment and behavioral symptoms, including physical aggression and wandering. Incident reports documented episodes where the resident entered another resident's room, engaged in verbal and physical aggression, and required staff intervention. Despite these events and staff interviews confirming knowledge of the resident's behaviors, the care plan did not include interventions for wandering or aggression until after the deficiency was identified. The second resident was assessed as severely cognitively impaired with frequent wandering behavior. Observations showed the resident entering another resident's room and lying in their bed, with staff needing to redirect them. Staff interviews confirmed awareness of the resident's wandering, but the care plan did not address this behavior. The Care Plan Coordinator was unaware of the resident's wandering and had not updated the care plan accordingly, despite daily staff meetings to discuss resident behaviors.
Misappropriation of Narcotic Medications by LPN
Penalty
Summary
The facility staff failed to prevent the misappropriation of narcotic medications belonging to three residents. This incident involved an LPN who took the medications without authorization. The facility's Abuse Policy defines misappropriation as the wrongful use of a resident's belongings without consent. The issue came to light when the ADON was notified of the LPN's suspicious behavior during a shift. Upon investigation, the ADON and LPN C discovered that three narcotic log sheets and medication cards were missing from the medication cart. The missing items were later found in the trash, and the LPN was arrested after a positive drug test for oxycodone. The residents affected by this incident were cognitively intact and had specific medical conditions requiring pain management. One resident had unspecified pain and was prescribed oxycodone for severe pain. Another resident had arthritis and knee pain, with a prescription for hydrocodone. The third resident had necrosis of an amputation stump and was also prescribed hydrocodone. The narcotic log books for these residents did not contain the necessary log sheets for their medications, indicating a failure in medication management and documentation. Interviews with facility staff revealed that the LPN exhibited odd behaviors, such as not signing out narcotics properly and disappearing for extended periods. The ADON and Human Resources conducted a drug test, which confirmed the LPN's use of oxycodone without a prescription. The police were called, and the LPN was found with narcotic record sheets and medication packages in their vehicle. This incident highlights a significant breach in the facility's procedures for handling controlled substances, leading to the misappropriation of residents' medications.
Failure to Notify Family of Resident's Passing
Penalty
Summary
Facility staff failed to notify the responsible party of a resident's passing, as required by the facility's policy. The resident, who had been admitted to the facility with multiple cancer diagnoses and was receiving hospice services, passed away. The nurse's notes documented the time of death but did not include any record of contacting the next of kin or family. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the expectation was to notify the family, doctor, administrative staff, and coroner when a resident passes. However, the LPN admitted to not contacting the family, stating it had slipped through the cracks, and later asked hospice to make the notification. The resident's next of kin reported not being notified by the facility and only learned of the passing through hospice hours later. This oversight indicates a failure to adhere to the facility's policy on notifying the family or responsible party in the event of a resident's death. The facility's census at the time was 67, and the deficiency was identified through interviews and record reviews conducted by surveyors.
Inadequate Staffing in Accordance with Facility Assessment
Penalty
Summary
The facility failed to provide adequate nursing staff in accordance with their Facility Assessment, which outlined the staffing requirements necessary to meet the needs of their residents. The assessment, dated April 10, 2024, specified that for an average census of 70-80 residents, each unit (West and East) required one Registered Nurse (RN) or Licensed Practical Nurse (LPN) per shift. However, a review of the facility's night shift staff schedules from April 20, 2024, to July 18, 2024, revealed that the facility consistently scheduled only one LPN for both the West and East units, failing to meet the staffing requirements as directed in the facility assessment. Interviews conducted on July 18, 2024, with the Director of Nursing (DON) and the administrator confirmed the staffing deficiencies. The DON acknowledged that while a licensed nurse was always scheduled for each shift, the facility did not always have two licensed nurses as required. The DON was unaware that the facility assessment mandated two licensed nurses at night. Similarly, the administrator was not aware of the requirement for two licensed nurses per unit, per shift, as stated in the facility assessment.
RN Staffing Deficiency
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by their Resident Services Policy. The facility's RN staff schedule for June and July 2024 showed multiple days without an RN on duty, specifically on weekends. Interviews revealed that the facility is currently short two RN positions, with the Director of Nursing (DON) and a Certified Nurse Aide (CNA) instructor, who is also an RN, covering shifts during the week. The administrator acknowledged the staffing shortage and the lack of RN coverage on weekends, indicating efforts to hire additional RNs.
Deficiencies in Water Management and Infection Control Procedures
Penalty
Summary
The facility staff failed to develop and implement comprehensive policies and procedures for the inspection, testing, and maintenance of the facility's water systems, which are crucial to inhibiting the growth of waterborne pathogens such as Legionella. The absence of a detailed water management program, including a water system flow diagram and specific control measures, was noted. The maintenance director admitted to performing only basic checks and cleaning procedures, lacking a thorough understanding of the CDC Toolkit requirements. This oversight potentially exposes residents to the risk of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Additionally, the facility staff did not adhere to appropriate infection control procedures during blood glucose monitoring for three residents. An LPN was observed placing glucometers on unsanitized surfaces without using a barrier, both before and after testing residents' blood sugar levels. This practice was contrary to the facility's policy, which mandates placing glucometers on clean surfaces to prevent the transmission of infectious agents. The Director of Nursing and the administrator were unaware of these lapses in protocol, which could lead to the spread of bloodborne pathogens or bacteria. Interviews with the LPN and the Director of Nursing revealed a lack of awareness and adherence to infection control expectations. The LPN acknowledged the importance of using a barrier but failed to do so due to the unavailability of one at the time. The Director of Nursing expressed that placing glucometers on unsanitized surfaces poses a risk for infection transmission, highlighting a gap in staff training and compliance with infection prevention protocols.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
Facility staff failed to designate a qualified individual with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist for the facility's infection prevention and control program. The facility, with a census of 70, did not provide a policy for specialized training for the Infection Preventionist. During an interview, the administrator stated that the Assistant Director of Nursing (ADON) was designated as the facility's Infection Preventionist. However, the ADON had only started the required training classes the previous month and was not yet certified. The administrator acknowledged that the training and certification needed to be completed before the ADON could officially assume the role of Infection Preventionist. In a subsequent interview, the ADON expressed unawareness of being the designated Infection Preventionist, as they were still enrolled in the Centers for Disease Control and Prevention Infection Preventionist training and had not completed the certification. The ADON mentioned being only halfway through the training modules and was aware that certification was required before assuming the title of Infection Preventionist.
Failure to Update Care Plans After Significant Events
Penalty
Summary
The facility staff failed to review and revise care plans for several residents following significant events, such as falls and the development of pressure ulcers. For Resident #13, the care plan was not updated to reflect a fall that occurred on 06/11/24, despite the resident having moderate cognitive impairment and a diagnosis of quadriplegia. Similarly, Resident #21's care plan did not include documentation of a fall on 06/26/24, which resulted in a major injury, even though the resident was assessed as cognitively intact. Resident #36 also experienced a fall on 04/24/24, but the care plan lacked any updated interventions. Resident #44's care plan was missing documentation for a fall on 07/04/24 and a stage III pressure ulcer, despite the resident having multiple diagnoses, including Alzheimer's disease and diabetes mellitus. Resident #52, who has severe cognitive impairment, suffered a fall on 07/06/24, but the care plan was not updated to include this incident. Additionally, Resident #5's care plan did not document a stage IV pressure ulcer, even though the resident was assessed with severe cognitive impairment and diabetes mellitus. The facility also failed to address and update care plans regarding behaviors for Resident #4, who has severe cognitive impairment and a history of behavioral symptoms. Despite a documented altercation on 06/22/24, the care plan did not include strategies for managing the resident's behaviors. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and education regarding these incidents, and the Director of Nursing acknowledged the responsibility of the Care Plan Coordinator to update care plans with necessary interventions.
Failure to Implement Grievance Policy for Missing Items
Penalty
Summary
The facility failed to implement its Grievance Policy for two residents who reported missing personal items. Resident #7, assessed as cognitively intact, reported a missing Bluetooth earbud set to the administrator but did not receive any update or replacement. The administrator was unaware of the missing item. Similarly, Resident #25, also assessed as cognitively intact, reported a missing cell phone to both the administrator and the business office manager but did not receive any update or replacement. The business office manager acknowledged the report but had not discussed further actions with the administrator. The facility's grievance binder contained only two grievance forms from 2024, indicating a lack of documentation for past grievances. Interviews with the business office manager, director of nursing, and administrator revealed inconsistencies in the grievance process, including delays in filling out grievance forms and a lack of follow-up on reported grievances. The facility did not maintain evidence of grievance resolutions for the required three-year period, as stipulated in their policy.
Failure to Investigate and Document Bruises of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate and document bruises of unknown origin for a resident, as directed by the facility's policy. The facility's Abuse Policy and Procedures/Investigation Protocols require a comprehensive investigation for injuries of unknown source, including documentation, notification of responsible parties, and a series of assessments and interviews. However, the resident's medical record did not contain documentation of the bruises or an investigation into the injury. The resident, who has intact cognition, is dependent on staff for certain activities and has a history of falls, was observed with bruises on the forehead and lateral right eye area. Interviews revealed that the CNA noticed the bruises during a shower but did not document them, assuming the nurse was already aware. The NP also observed the bruises but did not communicate with staff, assuming they were already informed. The DON was not notified in a timely manner and admitted to not knowing how to proceed with the investigation. The Administrator confirmed the expectation for such incidents to be reported and investigated, but acknowledged the delay in notification and investigation. This lack of communication and failure to follow protocol led to the deficiency.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
Facility staff failed to adhere to professional standards of practice by not completing neurological assessments for three residents following unwitnessed falls. The facility's policy mandates that after an incident involving a head injury or an unwitnessed fall, a nurse must perform neurological assessments and document the results on a flow sheet. These assessments should include checks every 15 minutes for the first hour, every 30 minutes for the next two hours, and every shift until 72 hours have passed. However, the medical records for three residents, who experienced unwitnessed falls, did not contain the required neurological checks as per the facility's policy. Resident #7, assessed as cognitively intact, had an unwitnessed fall with no injury documented, but lacked the necessary neurological checks. Resident #21, also cognitively intact, experienced an unwitnessed fall with a major injury, yet their medical record did not include the required assessments. Resident #36, with moderate cognitive impairment and dependent on assistance for mobility, had an unwitnessed fall with no injury, but similarly, their record was missing the neurological checks. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the expectation for neurological checks following unwitnessed falls, which were not completed in these cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Facility staff failed to store and label medications in a safe and effective manner, as observed during a survey. The survey revealed that multiple opened multi-dose medication bottles, such as vegetable laxative, diphenhydramine, ibuprofen, calcium, and milk of magnesia, were undated on the west wing medication cart. Additionally, the [NAME] wing medication storage room contained undated bottles of dietary supplements and Vitamin D3. This lack of proper labeling contravenes the facility's policy, which mandates that staff record the open date on multi-dose medication containers. Furthermore, the survey found that the medication refrigerator in the [NAME] wing medication storage room contained various food items, including a cinnamon roll, sandwiches, pizza, butter, soda, chipotle ranch, lime juice, leftovers, and coffee. This is contrary to the facility's policy, which requires medications to be stored separately from food. Interviews with staff, including a certified medication technician (CMT), a licensed practical nurse (LPN), the Director of Nursing (DON), and the administrator, revealed a lack of awareness and adherence to the facility's policies regarding medication labeling and storage. The DON acknowledged the issue of food being stored with medications and mentioned ongoing efforts to find a solution.
Residents Denied Weekend Access to Trust Funds
Penalty
Summary
The facility failed to ensure that six residents had appropriate access to their trust fund accounts during weekends. The facility's policy allowed residents to access their funds only from Monday to Friday, between 9:00 A.M. and 4:00 P.M., excluding holidays. This policy required residents to request funds on Fridays if they needed money for the weekend. Interviews with the residents revealed that they were unable to access their funds on weekends, which affected their ability to engage in activities such as dining out or shopping with family. All six residents involved were assessed as cognitively intact, indicating they were aware of their financial needs and the limitations imposed by the facility's policy. Interviews with facility staff, including an LPN, the Business Office, the DON, and the administrator, confirmed that there was no staff available on weekends to provide residents with access to their funds. The staff members were unaware that residents were required to have access to their money on weekends. This lack of awareness and the facility's restrictive policy led to the deficiency, as residents were unable to manage their financial affairs as needed during weekends.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the residents' interests on weekends for three residents out of a census of 70. The facility's policy requires an ongoing program to support residents in their choice of activities, including both group and individual activities. However, the activity calendar for June 2024 showed a lack of scheduled activities on weekends, with only occasional bingo and church services. Interviews with residents revealed dissatisfaction with the lack of weekend activities, as they expressed a desire for more engagement during these times. Interviews with facility staff, including a CNA, LPN, Activities Director, DON, and Administrator, confirmed the absence of scheduled activities on weekends. The Activities Director mentioned that an assistant helps with activities one weekend a month, but otherwise, weekend activities are left to the receptionist or CNAs if they have time. The DON and other staff were unaware of any scheduled weekend activities, indicating a lack of coordination and communication regarding the activity program. This deficiency highlights the facility's failure to adhere to its policy and meet the residents' needs for weekend activities.
Failure to Protect Resident Privacy
Penalty
Summary
The facility staff failed to maintain the confidentiality of personal medical information for three residents, as observed during a survey. The facility's policy on Resident Confidentiality and HIPAA mandates that protected health information should only be discussed with those directly responsible for a resident's care and treatment. However, observations revealed that a Certified Medication Technician (CMT) left residents' Electronic Health Records (EHR) open and visible to others, compromising their privacy. Specifically, the CMT left the EHR open while administering medications to three residents, and the medication cart was left unattended with the EHR visible at the nurse's station. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the administrator, confirmed that staff are instructed to lock or close screens when not at the medication cart to protect resident information. The CMT admitted to having a habit of leaving EHR records open, acknowledging it as an oversight. The ADON and administrator expressed awareness of the importance of following HIPAA regulations but were unsure why the EHRs were not being locked as required.
Improper Handling and Documentation of Controlled Substances
Penalty
Summary
The facility staff failed to adhere to professional standards regarding the handling and destruction of controlled substances. Specifically, the Director of Nursing (DON) was involved in the improper destruction of narcotics for Resident #4, where 30 Oxycodone tablets were documented as wasted without a second witness signature, as required by the facility's policy. The Assistant Director of Nursing (ADON) discovered the discrepancy and reported it to the administrator after confirming with a Registered Nurse (RN) that they did not participate in the destruction, contrary to the DON's claim. Additionally, the Certified Medication Technician (CMT) involved was pressured by the DON to sign off on the destruction, despite not being a nurse, and feared job loss for questioning the DON's actions. For Resident #5, the facility failed to maintain proper documentation for the destruction of a card of Hydrocodone. The DON signed out the medication, but no destruction sheet was found in the records. A family member of another resident reported that the Hydrocodone was removed from the narcotic box after they expressed a preference for it to be used only as a last resort. The DON claimed to have wasted the narcotics but could not recall who witnessed the destruction, and no documentation was available to verify the claim. Additionally, the facility staff did not follow proper procedures for medication administration. An observation revealed that medication cups with various pills were pre-prepared and labeled with handwritten last names, without listing the medication names. A CMT admitted to removing all medications needed for a 12-hour shift from the ISTAT at once to save time and due to a belief that opening the ISTAT incurred costs. The ADON and administrator confirmed that pre-popping medications was against policy due to the risk of errors, and staff were expected to administer medications immediately after gathering them.
Medication Storage Deficiency Due to Unlocked Carts
Penalty
Summary
Facility staff failed to ensure the secure storage of medications, leading to a deficiency in maintaining a safe environment for residents. The facility's policy, revised in December 2012, mandates that medication carts must be kept closed and locked when not in the direct sight of the medication nurse or aide. However, observations on multiple occasions revealed that a Certified Medication Technician (CMT) left the medication cart unlocked and unattended in the hallway, with keys left in the lock. This occurred at various times throughout the day, indicating a repeated oversight in following the facility's medication storage policy. Further observations showed a treatment cart left unlocked and unattended, containing 15 insulin pens, which were accessible to unauthorized individuals. Interviews with the Assistant Director of Nursing (ADON) and the CMT confirmed that the carts should be locked to prevent access by other staff, residents, or visitors. The CMT admitted to accidentally leaving the cart unlocked, acknowledging the importance of securing the cart for resident safety. The facility administrator also confirmed the requirement for carts to be locked when not attended, but could not explain why this protocol was not being followed.
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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