Marshfield Care Center For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshfield, Missouri.
- Location
- 800 South White Oak, Marshfield, Missouri 65706
- CMS Provider Number
- 265577
- Inspections on file
- 26
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Marshfield Care Center For Rehab And Healthcare during CMS and state inspections, most recent first.
The facility did not provide timely showers in accordance with resident preferences and care plans, resulting in several residents experiencing long gaps between showers and expressing dissatisfaction with their hygiene. Staff interviews revealed that showers were often missed due to staffing shortages and lack of a dedicated shower aide, and documentation of bathing and skin assessments was incomplete or missing.
Surveyors found the medication room cluttered with a large quantity of unused medications, including various prescription drugs awaiting destruction, due to the facility's failure to maintain a timely process for medication disposal. Multiple staff, including a CMT, LPN, ADON, and DON, acknowledged the ongoing disorganization and backlog, with the DON stating that the process and paperwork for destruction had not been completed for months.
A resident's code status was not clearly documented or accessible in required locations, leading to a delay when staff could not quickly determine the appropriate emergency response during a medical event. Staff interviews revealed that code status information was inconsistent and not updated due to a vacancy in the Social Services Director position, resulting in confusion and delayed initiation of CPR.
A resident with multiple medical conditions suffered a fall resulting in a fracture, but staff failed to notify the family and physician promptly, did not complete or document a full assessment or neurological checks, and did not initiate required fall monitoring. The facility also lacked policies and procedures for fall documentation and notification.
The facility failed to ensure that ordered medications were available and administered as prescribed, resulting in three residents missing multiple doses of essential medications. Staff did not consistently notify physicians when medications were unavailable, and there was confusion among staff regarding the use of the emergency medication kit and the process for obtaining medications for new admissions.
A resident with multiple risk factors for skin breakdown experienced deterioration and infection of pressure ulcers due to staff failing to provide wound care as ordered, incomplete and untimely wound assessments, and lack of care plan updates. Wound treatments were frequently undocumented or missed, and communication lapses among staff led to delayed recognition and management of new and worsening wounds, ultimately resulting in hospitalization for wound infection and abscess.
Staff failed to perform proper hand hygiene and did not follow Enhanced Barrier Precautions during wound care for three residents, including those with MRSA and surgical wounds. Supplies were reused after being dropped on the floor, shared between residents without disinfection, and EBP signage and PPE carts were not consistently available. Staff interviews revealed a lack of training and awareness regarding EBP, and facility policies on infection control were not followed in practice.
Surveyors found that food was not consistently protected from contamination due to unclean kitchen and serving areas, including debris and dried substances on the steam table, plate warmer, and toaster, as well as expired condiments in the serve-out refrigerator. Staff interviews revealed cleaning responsibilities were shared but not always completed due to limited staffing, and there was no clear policy for kitchen cleaning.
A staff member witnessed another staff verbally abusing a resident with cognitive impairment and reported it to the charge nurse, but the incident was not documented or reported to administration or the State Survey Agency within the required two-hour timeframe. The online report was submitted the next morning, and there was no evidence of timely investigation or proper notifications as required by facility policy.
A facility failed to promptly and thoroughly investigate an allegation of verbal abuse after a nurse aide reported witnessing another aide use profane language toward a resident with cognitive impairment and physical debility. The investigation was delayed, lacked comprehensive staff interviews, and did not include timely documentation or proper notifications, contrary to facility policy.
The facility failed to maintain food safety by improperly stacking wet dishware, not separating dented cans, and not ensuring staff wore appropriate hair restraints. Observations showed wet cups stacked together, dented cans stored with others, and a dietary aide with hair exposed while handling food, contrary to facility policies and FDA Food Codes.
The facility failed to provide written notification to residents and/or their representatives for hospital transfers, as required by policy. Three residents were transferred without documented notification, despite multiple instances of hospital transfers due to health issues. Interviews with staff revealed a lack of awareness and practice regarding the provision of transfer forms.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon hospital transfer. Three residents were transferred without receiving the required documentation, despite the facility's policy. Interviews revealed staff were unaware of the requirement, indicating a systemic issue in policy adherence.
The facility failed to maintain a sanitary environment in the kitchen and dining areas, with dead bugs found in light fixtures. Observations showed bugs in multiple lights, and interviews revealed a lack of communication and awareness among staff regarding maintenance responsibilities. The facility lacked a policy for light fixture maintenance, contributing to the oversight.
A resident with bradycardia and Parkinson's disease was administered diltiazem despite physician orders to hold the medication if systolic blood pressure was below 110 mmHg. The medication was given on multiple occasions when the resident's blood pressure was below this threshold, as documented by a CMT. Interviews with staff, including the LPN, DON, and Administrator, confirmed the failure to adhere to the prescribed parameters, highlighting a deficiency in medication monitoring.
A resident with diabetes received insulin without the pen being primed, as required by the manufacturer's instructions. An LPN administered the insulin without priming, believing it was unnecessary, despite the resident's high blood sugar level. Interviews revealed inconsistent practices among staff, with the DON confirming that priming is part of the training provided. Facility policies did not address priming insulin pens.
A facility failed to maintain an effective pest control program, resulting in a gnat infestation in a room shared by two residents. One resident, with no cognitive impairment, reported that the other, with severe cognitive impairment, left food and cups in the room, attracting gnats. Staff were aware of the issue but did not effectively address it, and the Administrator was unaware of the problem until it was pointed out. Despite some efforts, the facility's actions were insufficient to prevent the ongoing presence of gnats.
Failure to Provide Timely Showers and Support Resident Choice
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing timely bathing for four out of seven sampled residents. Facility policy required that residents receive showers in accordance with their preferences, care plans, and scheduled protocols, with staff responsible for assisting with bathing, performing skin assessments, and documenting these activities. However, documentation and interviews revealed that several residents did not receive showers as scheduled, with significant gaps between showers and incomplete records for October and November. Residents expressed dissatisfaction, noting that they felt unclean and that their preferences for at least weekly or biweekly showers were not honored. One resident with Alzheimer's disease and COPD required substantial assistance with ADLs and was care planned for weekly showers, but records showed only two showers in October and one in November, with a 16-day gap between some showers. Another resident, cognitively intact but needing assistance due to radiculopathy and dementia, was scheduled for weekly showers but experienced a 21-day gap between documented showers. A third resident, also cognitively intact and with a below-the-knee amputation, was care planned for twice-weekly showers but received only two showers in over a month. A fourth resident, recently admitted and with acute and chronic respiratory failure, reported going eleven days before being offered a shower, despite a preference for frequent showers and no care plan or nursing notes documenting bathing. Staff interviews confirmed that showers were often missed due to staffing shortages and lack of a dedicated shower aide. The shower schedule was posted daily, but aides reported difficulty completing showers when short-staffed, and documentation was inconsistent. Leadership acknowledged the issue, noting that the number of completed shower sheets was lower than expected and that improvements were needed. Residents' preferences for bathing were not consistently honored, and documentation of showers and skin assessments was incomplete or missing.
Failure to Timely Destroy and Account for Unused Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the proper storage, destruction, and accountability of medications. During an observation of the medication room, surveyors found the counter space cluttered with a large quantity of unused medications, including medication cards, bottles, bags, and individual doses for 22 residents. Additional medications were found stored in a white bucket above the medication refrigerator. The medications included a variety of prescription drugs such as muscle relaxants, antibiotics, blood pressure medications, and insulin, all of which were no longer in use and awaiting destruction. The facility's policy required unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and regulations, and for the destruction process to be witnessed and documented appropriately. Interviews with staff confirmed the ongoing issue. A Certified Medication Tech stated that the medication room was a mess and contained non-narcotic medications that were no longer in use, and that nursing managers were responsible for destroying expired medications. An LPN and the ADON both acknowledged that the medication room was disorganized and full of medications pending destruction, with the ADON noting that it had been several months since the room was clean and orderly. The MDS Coordinator described the room as a disaster that had been in that state for at least a couple of months. The DON admitted that the medication room was currently a mess, with a significant backlog of non-narcotic medications needing destruction, and that the process and paperwork required to address the issue had not been completed due to time constraints. The Interim Administrator also confirmed that the medication room should be kept clean and organized, and that all medications not in use should be destroyed in a timely manner. The facility's failure to maintain a process for the timely destruction of unused medications resulted in a cluttered and disorganized medication room, contrary to facility policy and regulatory requirements.
Failure to Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to maintain a clear and accessible procedure for documenting and communicating a resident's code status and advance directives, as required by its own policy. For one resident, the code status was not documented in the designated sections of the medical record, including the face sheet, physician orders, and the code status book. During a medical emergency, staff were unable to quickly locate the resident's code status, resulting in a delay in initiating CPR. The resident's admission baseline care plan indicated full code status, but this information was not consistently reflected or easily accessible in other required documentation locations. Multiple staff interviews confirmed that code status information should be available in the resident's chart, on the door, and in the code status book at the nurses' station, with all sources matching. However, staff reported that the Social Services Director (SSD), who was responsible for updating and auditing code status information, had not been in the position for some time, leading to discrepancies and outdated records. The newly hired SSD was in the process of auditing and updating code statuses, but at the time of the incident, the information was not current or consistent across all required locations. During the emergency, the LPN was unable to find the resident's code status after searching the physician orders, face sheet, and code status book, resulting in a delay of approximately five minutes before CPR was initiated. Other staff corroborated the difficulty in locating the code status and the expectation that this information should be readily available and consistent. The lack of clear documentation and communication of the resident's code status directly contributed to the delay in providing appropriate emergency care.
Failure to Notify and Monitor After Resident Fall Resulting in Fracture
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall resulting in a fracture. The staff did not notify the resident's family or physician in a timely manner following the fall with possible injury. Documentation of the initial assessment and ongoing fall monitoring, including neurological checks, was not completed as required. The facility also lacked a policy and procedure related to falls, fall documentation, and fall notifications. The resident involved had diagnoses including Alzheimer's disease, muscle weakness, high blood pressure, and respiratory failure, and required supervision and a walker for mobility. After the fall, the resident was found on the floor complaining of pain in the left hip and was assisted back to bed by staff. The LPN on duty did not document a full assessment, including baseline neurological checks, and did not notify the physician or the resident's family at the time of the incident. Vital signs were reportedly obtained but not documented, and the nurse did not initiate required fall monitoring or incident reporting procedures. Subsequent shifts identified the resident's continued pain and loss of independence with mobility, leading to an x-ray that revealed a probable fracture. Only then were the physician and family notified, and the resident was transferred to the hospital. Interviews with staff and leadership confirmed that the expected process for falls was not followed, including assessment, documentation, notification, and monitoring. The deficiency was further compounded by the absence of a facility policy on falls and related documentation.
Failure to Provide Timely Medications and Notify Physicians of Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring that ordered medications were available for administration and by failing to notify physicians when medications were unavailable. This resulted in three residents not receiving their prescribed medications as ordered. The facility's own policy required medications to be administered as ordered by the physician and in accordance with professional standards, but this was not followed in these cases. One resident with multiple chronic conditions, including multiple sclerosis, hypothyroidism, and restless legs syndrome, did not receive several medications for multiple days after admission. Documentation showed that doses of pantoprazole, venlafaxine, mirabegron, and ropinirole were not administered due to the drugs not being available. There was no documentation that the physician was notified of these missed doses. The resident reported not refusing any medications and expressed that missing these medications for several days would negatively affect their well-being. Another resident with a history of pulmonary embolism, hypertension, and congestive heart failure also did not receive several ordered medications, including antihypertensives, supplements, and an antifungal, due to unavailability. Again, there was no documentation of physician notification regarding the missed doses. A third resident, who had chronic pain following a leg amputation, did not receive pregabalin for several days because the prescription was not renewed in time and the medication was not available, despite some doses being present in the emergency kit. Staff interviews revealed confusion about the process for obtaining and administering medications from the emergency kit and inconsistent practices regarding physician notification when medications were unavailable.
Failure to Provide and Document Pressure Ulcer Care per Physician Orders
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards and its own policies, resulting in the deterioration and infection of wounds for a resident. Staff did not consistently provide wound care as ordered by the physician, with multiple instances where wound treatments were not documented as completed on the Treatment Administration Record (TAR) for both the right heel and right gluteal fold wounds. There was also a lack of documentation explaining missed treatments, and the care plan was not updated to reflect the resident's actual skin breakdown and current wound treatments. The resident involved had significant risk factors, including a history of stroke with left-sided weakness, diabetes with circulatory complications, incontinence, and was admitted with a pressure ulcer. Despite these risks, staff failed to conduct timely and complete wound assessments, did not update the care plan to address new or worsening wounds, and did not ensure that wound care orders from the external wound care provider were entered and followed. The wound care provider's notes indicated periods of wound improvement and deterioration, with changes in wound size, drainage, and the presence of nonviable tissue, but these changes were not consistently addressed by facility staff. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the ADON, and the Administrator, revealed a lack of awareness and communication regarding the resident's wounds, inconsistent documentation practices, and failure to notify the wound care provider of new or worsening wounds. The resident ultimately developed an abscess with purulent drainage requiring hospital transfer and surgical intervention. Throughout the period reviewed, the facility did not maintain accurate and timely wound care records, did not follow physician orders, and did not update the care plan as required.
Failure to Implement Effective Infection Control and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple staff not performing proper hand hygiene and not following Enhanced Barrier Precautions (EBP) during wound care for three residents. Observations revealed that staff, including LPNs and the MDS Coordinator, did not perform hand hygiene before or after glove changes, after contact with potentially contaminated surfaces, or between different wound care tasks. Supplies such as wound cleanser bottles and dressings were placed on potentially contaminated surfaces without barriers, dropped on the floor and reused, and shared between residents, including those with MRSA, without proper disinfection or dedicated use. For one resident with a history of stroke, diabetes, and MRSA in a buttock wound, staff failed to perform hand hygiene at multiple points during wound care, reused supplies that had fallen on the floor, and returned unused supplies from the resident's room to the general treatment cart. Similar lapses were observed with two other residents, one with diffuse large B-cell lymphoma and surgical wounds, and another with MRSA infection and heart failure. In all cases, EBP signage was missing, PPE carts were not consistently available, and staff did not consistently use gowns and gloves as required for high-contact care activities. Interviews with staff and leadership revealed a lack of training and awareness regarding EBP, with several staff members unable to define EBP or describe when and how to implement it. Staff also reported inconsistent practices regarding the use and disposal of wound care supplies, hand hygiene, and PPE. Facility policies required hand hygiene and the use of PPE, but these were not followed in practice, and there was no evidence of staff education or competency assessment on EBP.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, resulting in multiple instances where food was not protected from possible contamination. Observations throughout the day revealed that the chrome surfaces surrounding the water wells of the steam table, the plate warmer, and the lower shelf of the steam table were consistently covered with debris, dried food particles, and dried liquid substances. The trash can lid was also found splattered with dried substances, and a tub of butter was left on the back counter with a spatula covered in butter resting on top. The toaster on the back counter was observed to be covered in crumbs, with the inside containing a layer of crumbs and dried substances on the chrome edging. These unsanitary conditions persisted throughout multiple observations at different times of the day, indicating a lack of thorough cleaning and maintenance of non-food contact surfaces in the kitchen and serving areas. Interviews with staff, including dietary aides, cooks, the Dietary Manager (DM), the Administrator, and the Director of Nursing (DON), confirmed that the responsibility for cleaning the dining room tables, steam table, plate warmer, microwave, toaster, and serving area countertops after each meal was shared among the kitchen staff. However, staff reported difficulty in completing all required cleaning tasks between meals due to limited staffing, with only two kitchen staff working each shift. The facility did not have a policy regarding cleaning the kitchen and/or serving station, and the daily deep cleaning schedule outlined specific tasks for certain days but did not ensure consistent cleanliness after each meal service. Additionally, the facility failed to ensure that condiments kept in the serve-out refrigerator were not expired. Observations showed several condiments in squeeze bottles, such as mustard, mayonnaise, salad dressing, and barbecue sauce, were hand-labeled with use-by dates. Interviews revealed that some kitchen staff were new and not yet in the habit of checking use-by dates on condiments and other food items. Staff were expected to label bottles to be used within seven days and discard contents after that date, but this practice was not consistently followed, leading to the presence of expired condiments in the refrigerator.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse by a staff member toward a resident was reported immediately to facility management and to the State Survey Agency within the required two-hour timeframe. According to the facility's policy, all allegations of abuse, including verbal abuse, must be reported to the administrator and the State Survey Agency no later than two hours after the incident. In this case, a nurse aide witnessed another aide verbally abusing a resident by using profane language and reported the incident to the charge nurse between 10:15 P.M. and 10:20 P.M. However, there was no documentation by the charge nurse regarding the allegation, and no immediate notification was made to the administration or the State Survey Agency as required. The resident involved had a history of age-related physical debility, mild cognitive impairment, and generalized anxiety disorder, and required assistance with daily activities. The resident's care plan indicated communication problems and cognitive loss, necessitating respectful and clear communication from staff. Despite these vulnerabilities, the facility's documentation showed a lack of timely and appropriate response to the reported abuse, with no evidence of staff interviews (other than the accused aide), no summary statement, and no documentation of notifications to the administration, physician, or the resident's family. The online report to the State Survey Agency was not made until the following morning, well beyond the required two-hour window. Interviews with various staff members confirmed their understanding that all abuse allegations should be reported immediately and to the State within two hours. The administrator and DON acknowledged that the incident constituted verbal abuse and should have been reported promptly, and that the charge nurse failed to ensure timely notification and initiation of an investigation.
Failure to Timely and Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to document a timely and thorough investigation into an allegation of verbal abuse involving a resident. A nurse aide reported witnessing another aide enter a resident's room and use profane language, calling the resident derogatory names and instructing them to stop contacting their family. The reporting aide stated that the charge nurse was notified of the incident shortly after it occurred, but there was no immediate initiation of an investigation or documentation of the allegation in the resident's medical record. The resident involved had a history of age-related physical debility, mild cognitive impairment, and generalized anxiety disorder, and required assistance with daily activities. The resident's care plan noted communication problems and cognitive loss, emphasizing the need for respectful staff interactions. Despite these vulnerabilities, the facility's investigation documentation was limited to a single witness statement and unsigned questionnaires from seven residents about their feelings of safety, with no evidence of interviews with other staff or documentation of notifications to administration, the physician, or the resident's family. Interviews with facility staff confirmed that allegations of abuse should be reported immediately and investigated by administration. However, the investigation was delayed because the initial notification to administration was not confirmed, and the investigation did not include comprehensive staff interviews or timely documentation. The administrator and DON acknowledged that the process was not followed as required by facility policy, which mandates immediate reporting and thorough investigation of abuse allegations.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain food safety standards by improperly handling clean dishware, which could lead to contamination. Observations revealed that staff stacked wet plastic cups on top of each other, trapping water between them, contrary to the 2022 Food Code and the facility's own policy, which require air drying of dishes before storage. Interviews with dietary aides and the dietary manager confirmed that dishes should be air-dried and not stacked while wet, yet this practice was not followed. Additionally, the facility did not adequately separate dented cans from other canned goods, posing a risk of contamination. Observations showed dented cans of apples stored alongside other cans, despite the facility's policy to set aside and discard dented cans. Interviews with dietary aides and the dietary manager indicated that dented cans should be placed in a separate area and not used, but this procedure was not consistently implemented. Furthermore, the facility did not ensure that staff wore appropriate hair restraints while handling food. A dietary aide was observed wearing a ball cap with hair hanging below it, without a hair net, while preparing and serving food. The facility's policy and the 2013 Food Code require hair to be effectively restrained to prevent contamination. Interviews with staff and the administrator highlighted a misunderstanding about the requirement for hair nets when wearing a ball cap, leading to non-compliance with the hair restraint policy.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding transfers or discharges to the hospital, as required by their policy. This deficiency was identified for three residents out of a sample of 18, with a facility census of 51. The facility's policy, revised in December 2016, mandates that details of a transfer or discharge be documented in the medical record and communicated to the receiving healthcare provider, and that appropriate notice be provided to the resident and/or legal representative. For Resident #3, multiple instances were noted where the resident was transferred to the hospital due to issues with a feeding tube, but there was no documentation of written notification provided to the resident or their representative. Similarly, Resident #4 was transferred to the hospital on two occasions due to health concerns, but again, there was no documentation of written notification. Resident #30 was also transferred to the hospital without documented written notification to the resident or their representative. Interviews with facility staff, including an LPN, the Social Service Director, the Director of Nursing, the Administrator, and the Director of Operations, revealed a lack of awareness and practice regarding the provision of transfer forms to residents and/or their representatives. The staff did not make copies of the transfer forms, and there was no system in place to ensure that residents or their representatives received the necessary documentation during transfers to the hospital.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for three residents who were transferred to the hospital for various medical reasons. The facility's policy mandates that residents or their representatives be informed in writing about the bed-hold policy prior to any transfers or therapeutic leaves, but this was not documented for the residents in question. Resident #3, who had diagnoses including acute kidney failure and schizophrenia, was transferred multiple times to the hospital due to issues with a feeding tube and other medical concerns. Despite these transfers, there was no documentation indicating that the resident or their representative received written information about the bed-hold policy. Similarly, Resident #4, who had mild cognitive impairment, was transferred to the hospital twice due to severe stomach pain and other symptoms, but again, there was no documentation of the bed-hold policy being provided. Resident #30, with conditions such as COPD and diabetes, was also transferred to the hospital without receiving the required bed-hold policy documentation. Interviews with facility staff, including the LPN, Social Service Director (SSD), Director of Nursing (DON), and Administrator, revealed a lack of awareness and training regarding the requirement to provide the bed-hold policy upon resident transfer. The SSD admitted to not sending the bed-hold policy to residents or their representatives and was unaware of this requirement until reviewing the policy. The DON and Administrator confirmed that the policy was not being sent as required, indicating a systemic issue in the facility's adherence to its own policies.
Sanitation Deficiency in Kitchen and Dining Areas
Penalty
Summary
The facility staff failed to maintain a sanitary and comfortable environment in the kitchen and dining areas, as evidenced by the presence of dead bugs in the light fixtures. Observations conducted on two separate occasions revealed several dead bugs in lights located just before entering the kitchen, above the refrigerator and freezer, and at the entrance of the kitchen. The facility did not have a policy regarding the maintenance of light fixtures, which contributed to the oversight. Interviews with various staff members, including dietary aides, the dietary manager, the maintenance director, and the administrator, highlighted a lack of communication and awareness regarding the issue. Dietary aides indicated that maintenance was responsible for cleaning the lights, but they were unsure of the frequency of cleaning. The dietary manager and maintenance director both stated that maintenance was responsible for the lights, with a monthly checklist in place, but neither was aware of the dead bugs. The administrator confirmed that maintenance was responsible and that kitchen staff should report issues in a requisition book, indicating a breakdown in the reporting and maintenance process.
Failure to Monitor Medication Parameters for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs due to inadequate monitoring of diltiazem administration. The resident, who had diagnoses including cognitive communication deficit, bradycardia, and Parkinson's disease, was prescribed diltiazem with specific parameters to hold the medication if the systolic blood pressure was below 110 mmHg. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the prescribed threshold, as documented by a Certified Medication Technician (CMT). This failure to adhere to the physician's orders was confirmed through interviews with the Licensed Practical Nurse (LPN), the CMT, the Director of Nursing (DON), and the Administrator, all of whom acknowledged the importance of following the medication parameters. The resident's care plan highlighted the risk of adverse reactions due to the variety of medications being administered, and the need for staff to administer medications as ordered. However, the staff did not comply with the order to hold diltiazem when the resident's blood pressure was below the specified level, potentially risking further hypotension. The DON and Administrator both expressed that they expected staff to follow physician orders and acknowledged that the medication should not have been administered when the resident's blood pressure was out of parameters.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility staff failed to ensure that all residents were free from significant medication errors when a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident. The resident, who was cognitively intact, had a medical history that included chronic obstructive pulmonary disease, high blood pressure, peripheral vascular disease, and diabetes. The resident's physician had ordered Novolog insulin to be administered subcutaneously with meals, and the resident's blood sugar level was recorded at 305 mg/dL before the insulin was administered. However, the LPN did not follow the manufacturer's instructions to prime the insulin pen, which involves selecting two units, tapping the cartridge to collect air bubbles, and ensuring a drop of insulin appears at the needle tip before administration. Interviews with facility staff revealed inconsistencies in the understanding and practice of priming insulin pens. The LPN involved in the incident believed that the pens were pre-dosed and pre-primed, and therefore did not require priming. In contrast, another LPN stated that they always prime insulin pens before use, and the Director of Nursing (DON) confirmed that staff are trained to prime insulin pens with two units of insulin before each use. The DON also stated that this training is provided upon hire and annually. The facility's policies on insulin administration and medication administration did not address the need to prime insulin pens, despite the manufacturer's instructions indicating its necessity.
Ineffective Pest Control Program Leads to Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple gnats in a room shared by two residents. One resident, who had no cognitive impairment, reported that the other resident, who had severe cognitive impairment, left food and cups in the room, attracting gnats. Observations over several days confirmed the presence of gnats around food items and cups in the room, with staff acknowledging the issue but not effectively addressing it. Interviews with various staff members, including a CNA, housekeeper, CMT, RN, and the Maintenance Director, revealed that the presence of gnats was known, particularly in the room of the resident with severe cognitive impairment. Staff reported attempts to manage the situation by picking up food and cups, and a pest control company was mentioned as spraying the facility. However, the Maintenance Director was not aware of the issue until recently and had only taken limited actions, such as installing plug-in devices in some rooms. The Administrator was unaware of the gnat problem in the specific room until it was brought to her attention during an observation. She stated that staff should report such issues to maintenance or administrative staff. Despite some efforts to address the problem, such as cleaning specific rooms and using pest control measures, the facility's actions were insufficient to prevent the ongoing presence of gnats in the residents' room.
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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