Nick's Health Care Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Plattsburg, Missouri.
- Location
- 253 East Highway 116, Plattsburg, Missouri 64477
- CMS Provider Number
- 265698
- Inspections on file
- 23
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Nick's Health Care Center, Llc during CMS and state inspections, most recent first.
A resident with a history of mental health disorders and identified risk for aggression physically assaulted another resident with significant physical limitations, causing facial injuries that required hospital treatment. The aggressor had a care plan noting risks for aggression and the need for protective oversight, but was still able to enter another resident's room and inflict harm. Staff and documentation confirmed the incident, and the injured resident reported feeling unable to defend themselves.
Surveyors found that the facility failed to maintain sanitary food service conditions by allowing a persistent fly infestation in the kitchen and dining areas and not repairing damaged kitchen structures. Flies were observed landing on food being prepped and served, with dead flies on floors and fly strips, and a misaligned back kitchen door left a large gap for insects to enter. The wall behind the cook stove was damaged with missing drywall, and flooring at the serving line was peeling and packed with debris, making cleaning difficult. The Dietary Manager knew about the wall and flooring problems but did not report them, and staff described flies as an ongoing issue despite traps and exterminator services. Two residents reported that flies were bothersome during meals, landing on their food and faces, while the Maintenance Director and Administrator acknowledged a fly problem but were unaware of some structural issues.
The facility failed to maintain an effective pest control program as required by its own policy, resulting in persistent flies in resident areas, including the entrance, dining room, hallways, and kitchen. Flies were repeatedly observed landing on residents, their food, and dining surfaces, with residents swatting them away during meals and activities and reporting that the flies constantly bothered them, especially while eating and in their rooms. In the kitchen, an open staff bathroom door and a fly strip completely coated with dead flies, with more flies flying around it, further demonstrated the infestation. The Housekeeping Services Manager and Administrator both acknowledged the fly problem but were unable to identify when pest control services were last provided or how to effectively manage the issue, and the facility could not produce documentation of recent pest control services.
Surveyors found that the facility did not use the required CMS-10055 Advance Beneficiary Notice of Non-Coverage form when discontinuing Medicare Part A benefits for three residents, including individuals with COPD, acute respiratory failure, muscle weakness, Type II diabetes, tremors, and stroke, and a resident receiving skilled nursing/rehab care. Instead, staff used an outdated CMS-R-131 form that did not document the Medicare Part A end date, and interviews with the Social Service Director and the Administrator revealed they were unaware that the incorrect ABN form was being used.
The facility failed to maintain timely and adequate laundry services, resulting in overflowing barrels of soiled linens and clothing, strong urine odors in the hallway outside the laundry near the dining area, and large amounts of clean laundry left unfolded and undelivered. A resident with intact cognition and multiple chronic conditions, who was independent with ADLs, was repeatedly observed in the dining room wearing a hospital gown because no clean personal clothing was available. An LPN reported that most residents lacked clean laundry due to insufficient laundry staffing, and residents in a group interview voiced concerns about delays in the return of their clothing. The facility could not provide a policy outlining laundry duties.
A resident with intact cognition and independent ADLs, who had multiple chronic conditions, requested transfer to another LTC facility to live closer to a special-needs child. Although an initial referral was reportedly sent by social services, there was no documentation in nursing or social service notes or in the care plan reflecting the resident’s wish to transfer, no recorded follow-up, and no documented communication back to the resident. The SSD and Administrator could not provide records of ongoing efforts, beyond a single text and an undated initial referral, while the receiving facility’s admissions nurse reported repeatedly requesting updated nursing notes and stating the original referral had expired after 30 days and needed to be resubmitted. This resulted in months of inaction on the resident’s transfer request and failure to support the resident’s right to self-determination.
A resident with cognitive deficits was injured after being hit by another resident who was frustrated with them going through their belongings. The injured resident was hospitalized with a nasal bone fracture and a shoulder fracture. The facility's policy on abuse prevention was not effectively implemented, leading to the incident.
A resident with a history of aggression struck another resident, causing a bloody lip, after becoming agitated when their path was blocked. Both residents have moderate cognitive impairments and complex medical histories. The facility's investigation noted the incident but determined it was not abuse, despite policies emphasizing the need to report and prevent such occurrences.
The facility served tough roast beef to residents, as confirmed by a test tray and resident council feedback. The Dietary Supervisor acknowledged the issue after tasting the meat, and the DON expected food to be easy to eat and visually appealing.
The facility failed to discard expired food items, improperly stored food in the walk-in refrigerator, and placed boxes on the floor of the walk-in freezer, contrary to its policies. Despite staff training, these deficiencies were observed, indicating a lapse in adherence to food safety standards.
The facility failed to control a fly infestation, affecting all 69 residents. Flies were observed in residents' rooms and at the nurses' station, with staff attempting to swat them away. A resident reported the flies as a significant nuisance, and staff confirmed the issue despite monthly pest control services. The Maintenance Director had not sought additional services to address the problem.
The facility failed to conduct required care plan meetings for two residents with moderate cognitive impairment. One resident did not have documented meetings from January to April, while the other missed a quarterly review after a September assessment. The DON and MDS Coordinator acknowledged these oversights.
The facility failed to timely report abuse allegations for two residents. One resident with moderate cognitive impairment reported inappropriate language from a staff member, and another with severe cognitive impairment reported verbal abuse by a peer. The Administrator delayed reporting these incidents to the state agency, contrary to facility policy requiring immediate notification.
The facility failed to develop comprehensive care plans for two residents, one with type two diabetes mellitus and another with Alzheimer's disease, hypertension, and mixed hyperlipidemia. The first resident's care plan did not address diabetes management, while the second resident lacked a care plan entirely. The MDS Coordinator and DON confirmed these oversights, which did not align with facility policy.
The facility did not adhere to its policy of posting daily nurse staffing information. Observations revealed missing or incorrectly dated staffing sheets over several days. Interviews indicated that the MR staff was responsible for posting but failed to do so consistently, leading to the deficiency.
The facility failed to maintain a clean environment in the main dining room, with dead bugs and cobwebs observed in the windowsill. A resident with intact cognition expressed concerns about the dining room's cleanliness. Interviews revealed confusion among staff about cleaning responsibilities, with the dietary department identified as responsible for the dining room. The DON and Administrator acknowledged the unsanitary conditions.
A facility failed to complete a PASARR for a resident who received new mental health diagnoses, contrary to its policy. The resident, admitted with major depressive disorder and anxiety disorder, was later diagnosed with PTSD and impulse disorder. Staff interviews revealed a lack of awareness about the need for a new PASARR, with the MDS Coordinator acknowledging the oversight and the DON mistakenly believing the diagnosis was pre-existing.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a history of schizophrenia, antisocial personality disorder, intermittent explosive disorder, and other mental health conditions physically assaulted another resident, resulting in significant facial injuries that required hospitalization. The aggressor resident was known to have mild cognitive impairment and a care plan that identified risks for physical or verbal aggression, delusions, hallucinations, and irritability. The care plan also noted the need for staff to be aware of the resident's body language and to provide protective oversight while maintaining the least restrictive environment. Despite these identified risks, the resident was able to enter another resident's room and inflict harm. The assaulted resident had intact cognition but significant physical limitations, including a left leg above-the-knee amputation and diagnoses such as Parkinson's disease, osteomyelitis, and HIV. This resident required substantial assistance with activities of daily living and was unable to defend themselves during the incident. The attack resulted in lacerations and facial fractures, as documented by both facility and hospital records. The injured resident reported feeling scared and unable to defend themselves due to physical weakness. Staff documentation and interviews confirmed that the aggressor resident self-reported the incident to staff, who then found the injured resident with facial wounds and bleeding. Prior to the incident, there had been no reported issues between the two residents, and staff had not observed any prior aggressive behavior from the aggressor. The facility's policies required identification and intervention in situations where abuse was likely, as well as protective oversight for residents at risk of aggressive behavior. However, the incident demonstrated a failure to prevent resident-to-resident abuse, resulting in harm.
Uncontrolled Fly Infestation and Poor Kitchen Maintenance Affecting Food Sanitation
Penalty
Summary
Surveyors identified a deficiency in sanitary food service conditions when the facility failed to control a persistent fly problem in the kitchen and dining areas and did not maintain kitchen surfaces, flooring, and doors in good repair. Observations showed flies in the kitchen landing on peaches in bowls and on salads being prepped, as well as clusters of flies on all surfaces and on food being prepared and served. Dead flies were seen on the floors by all prep areas and on a fly sticky strip hanging in the kitchen bathroom with the door open. The wall behind the cook stove had a section of the corner pushed in with missing drywall, and the kitchen flooring at the serving line was peeling away from the floor, with caked-on debris lodged between the laminate and the concrete, creating an area that could not be adequately cleaned. The back delivery door to the kitchen was lopsided in the frame, leaving a 1.5–2 inch gap that allowed flies and insects to enter the kitchen. The Dietary Manager reported being aware for about a week that the wall behind the stove was falling in but had not reported it to maintenance, and also knew the flooring by the serving line had been steadily coming up and was hard to keep clean, yet had not reported the floor issues. The Dietary Manager stated the exit door did not fit correctly, believed this was the main reason for the fly problem, and acknowledged the issue had been reported to maintenance at some point but had not submitted a new work order. A staff member stated flies were always a problem in the kitchen and that they were constantly swatting flies off food and prep areas, describing the fly problem as ongoing despite fly traps and exterminator involvement. Two residents reported that flies while eating were “ridiculous,” annoying, and that they did not like flies landing on their food or touching their faces while they tried to eat. The Maintenance Director, who had started two weeks prior, was unaware of the wall, floor, or door issues but acknowledged a fly problem, especially in the kitchen and dining room. The Administrator was aware of the fly problem and the misaligned kitchen door but was unaware of the wall and flooring issues, and stated residents have the right to live in a home without flies continually landing on them and their food.
Failure to Maintain Effective Pest Control Resulting in Persistent Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its Pest Control Program policy dated 5/14/24, which states the facility will eradicate common household pests such as flies. Surveyors observed flies throughout resident areas, including the main entrance, dining room, hallways, and on residents themselves during meals, cares, and activities. Flies were seen landing on residents’ food during the noon meal, on dining tables, and on residents’ faces and hands, with residents repeatedly swatting them away while trying to eat and drink. In the kitchen, a staff bathroom door was left open, and a sticky fly strip hanging from the ceiling was completely coated with dead flies, with additional flies flying around it. The facility was unable to provide documentation of the last pest control services performed. Residents reported that flies were a persistent problem, especially during meals and in their rooms, with one resident stating that flies were always bothering them and another stating that the flies “drive me crazy” when trying to eat. The Housekeeping Services Manager stated that the facility previously had a pest control company that came monthly but was unsure when they last serviced the building, did not know how to manage the fly problem, and did not know where to find pest control information. The Administrator acknowledged awareness of the fly problem and stated that pest control comes monthly but was unsure when the company last provided service for flies, noting the issue is worse in the summer months. The facility’s inability to verify current pest control services and the ongoing presence of flies on residents and their food demonstrate a failure to implement and maintain an effective pest control program as outlined in facility policy.
Failure to Use Correct ABN Form for Medicare Part A Discontinuation
Penalty
Summary
The facility failed to properly notify residents of changes in Medicare Part A coverage by not using the correct Advance Beneficiary Notice of Non-Coverage (ABN) form and by omitting required information. Facility policy, last revised on 11/05/24, stated that residents are to be informed in advance when changes occur to their bills and that CMS form 10055 would be provided prior to discharge from Medicare Part A. Record review showed that one resident admitted to Medicare Part A with COPD, acute respiratory failure, muscle weakness, and Type II diabetes was discharged from Medicare Part A on 05/07/25; another resident admitted for skilled nursing and/or rehabilitation care was discharged from Medicare Part A on 07/13/25; and a third resident admitted with COPD, tremors, and stroke was discharged from Medicare Part A on 08/28/25. Instead of using the required CMS-10055 ABN form, the facility used an outdated ABN form titled CMS-R-131 for all three residents. The outdated form did not include the date that Medicare Part A coverage would be ending for these residents, and review of the medical records confirmed that the current CMS-10055 ABN form was not present for any of them. During interviews, the Social Service Director stated she was unaware she was using the incorrect CMS form to notify residents about the discontinuance of Medicare Part A benefits and that CMS-10055 should have been used, and the Administrator stated he was unaware the correct ABN form was not being utilized.
Failure to Maintain Timely, Adequate Laundry Services and Homelike Environment
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by not providing adequate laundry services and by allowing strong urine odors to persist near the dining area. Surveyor observations on multiple days showed the laundry room, located off the hallway leading to the dining room, had a strong urine odor in the hallway and inside the room. Large barrels were overflowing with dirty linen and clothing, including soiled wet items, and both washing machines were full. Clean clothes were stacked approximately three feet high, waiting to be folded, hung, and sorted, and at times no laundry staff were present in the laundry room. The facility was unable to provide a policy regarding laundry duties. One resident, identified as Resident #49, had an intact cognition per a recent Quarterly MDS and diagnoses including schizoaffective disorder, COPD, and diabetes, and was independent with ADLs. This resident was observed in the main dining room on more than one occasion wearing a hospital gown with pants because there were no clean personal clothes available. An LPN stated that the resident did not have any clean personal clothing and had to wear a facility gown until clothes were cleaned, and further reported that the facility failed to maintain clean laundry for most residents due to lack of help in the laundry room. The resident reported hating wearing hospital gowns, preferring personal clothes, and stated this situation happened often and made the resident reluctant to leave the room without personal clothing. In a group interview, residents voiced concerns about delays in having their laundry returned.
Failure to Honor Resident’s Request to Transfer Closer to Family
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to self-determination and choice regarding transfer to another LTC facility closer to the resident’s family. The resident, who had intact cognition, was independent in ADLs, and had diagnoses including insulin-dependent diabetes, kidney disease, cervical cancer, and heart disease, had lived in the facility for three years and requested to move to a neighboring facility to be closer to a special-needs child living in a group home. The resident reported having made this request months earlier to social services and administrative staff, stating that no one had followed up and expressing emotional distress, saying that their rights had been violated. Record review from June through October showed no nursing or social service documentation of the resident’s wish to discharge to another LTC facility, no follow-up on the request, and no communication to the resident about the status of the transfer. The care plan contained no documentation of the resident’s desire to move closer to the child. The Social Services Director stated that an initial admission referral had been sent in May to the requested facility but could not locate documentation of the request, referral, follow-up, or timeline, and acknowledged that the referral had not been followed up, documented, or communicated to the resident. The Administrator was aware of the request and had only a single text message to the neighboring facility asking about referral status, with no further documentation of active work on the referral. The admissions nurse at the neighboring facility reported that updated nursing notes had been requested more than once, that referrals expired after 30 days, and that they were still waiting on an updated referral, with the original referral having been sent four months earlier.
Resident Assault and Injury Due to Inadequate Protection
Penalty
Summary
The facility failed to protect a resident from abuse when another resident hit them in the face, causing bodily injury. The incident involved two residents, one with significant cognitive deficits and a history of rummaging and taking items, and the other with moderate cognitive loss and no previous aggressive behaviors. The altercation occurred after the second resident became frustrated with the first resident going through their belongings, leading to the physical assault. The injured resident was found on the floor with a bloody nose and complained of shoulder pain. They were sent to the hospital for evaluation, where they were diagnosed with a non-displaced fracture of the humeral head and neck and a right nasal bone fracture. The resident's medical records indicated a history of behaviors not directed at others, such as rummaging and pacing, and rejection of care. The facility's policy on abuse and neglect emphasizes the prevention of abuse by identifying residents with increased vulnerability and providing interventions. However, the policy was not effectively implemented in this case, as the staff did not anticipate the conflict between the two residents. The incident was reported immediately to the Administrator and Director of Nursing, and the residents were separated following the event.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when one resident struck another in the face, resulting in a bloody lip. The incident involved two residents with moderate cognitive impairments and complex medical histories, including conditions such as Alzheimer's Disease, dementia, and schizophrenia for the aggressor, and cerebral palsy and quadriplegia for the victim. The aggressor, who has a history of potential verbal and physical aggression, became agitated when the victim, in a wheelchair, blocked their path to the bathroom. This led to the aggressor striking the victim in the face. The facility's investigation noted that the victim reported the incident to staff, who observed a small amount of blood on the victim's lip and an abrasion on the aggressor's hand. Both residents were separated, and physical assessments were conducted. The facility's policy on abuse and neglect emphasizes the need to report all allegations of abuse immediately and to identify residents with increased vulnerability for abuse. Despite these policies, the facility determined that the event was not a result of abuse, and the Director of Nursing and Administrator stated that the incident could not have been prevented by staff.
Tough Roast Beef Served to Residents
Penalty
Summary
The facility failed to ensure that the roast beef served for lunch was palatable and easy to eat for five residents who attended a resident council meeting. On the specified date, the planned menu included roast beef, mashed potatoes, mixed vegetables, and a mud cake. A test tray received by the surveyor contained the same meal, and it was noted that the roast beef was seasoned but tough and hard to cut. During the resident council meeting, five residents reported that the meat was tough. The Dietary Supervisor confirmed the residents' complaints after tasting the roast beef herself and acknowledged its toughness. The Director of Nursing expressed an expectation that the dietary staff should provide food that is visually appealing and easy for residents to eat, indicating that the food should not be tough.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to adhere to its policy on food storage and handling, which led to several deficiencies observed by the surveyor. During an inspection of the dry goods storage area, expired food items were found, including two packs of bread and a gallon bottle of hot sauce. Additionally, an unsealed five-pound box of pancake mix was noted. In the walk-in refrigerator, food items such as tuna salad and shredded cheese were past their use-by dates, and a five-pound bag of brown iceberg lettuce was improperly stored. Furthermore, in the walk-in freezer, five boxes of tater tots were found stored directly on the floor, contrary to the facility's policy that requires food to be stored off the floor and away from walls. Interviews with the Dietary Supervisor, Director of Nursing, and the Administrator revealed that the kitchen staff had been trained to discard expired food items, ensure all items were sealed, and avoid storing items on the floor. Despite this training, the deficiencies were still present, indicating a lapse in following the established procedures. The Director of Nursing and the Administrator both expressed their expectations that the kitchen staff should serve food that is fresh and safe to eat, highlighting a disconnect between the facility's policies and the actual practices observed during the survey.
Failure to Control Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program for the prevention and control of flies, which had the potential to affect all 69 residents. Observations revealed flies in residents' rooms and at the nurses' station, with staff attempting to swat them away. A resident with intact cognition reported that flies were a significant nuisance, crawling on them while they tried to rest, and expressed that the facility had not taken any measures to control or eliminate the flies. Interviews with staff, including an LPN and a housekeeper, confirmed the presence of a fly problem, despite the facility having a contract with a pest control company for routine services. The pest control representative confirmed that the facility received basic fly insect service monthly, but additional services were available if requested. The Maintenance Director acknowledged the presence of flies and stated that the pest control company only placed fly traps on the walls. Despite the monthly pest control visits, the Maintenance Director had not discussed any additional services to address the fly issue. The Director of Nursing and the Administrator were aware of resident complaints about the flies, but no effective action had been taken to resolve the problem.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for two residents, as required by their policy. Resident #15, who was admitted in 2018 and has a medical history including spinal stenosis and moderate cognitive impairment, did not have care plan meetings documented from January to April 2024. The Director of Nursing and the MDS Coordinator confirmed that only one care plan meeting was held in July 2024, despite the requirement for quarterly meetings. Similarly, Resident #56, admitted in 2022 with diagnoses of adjustment disorder and moderate cognitive impairment, did not have a care plan review after the quarterly MDS assessment in September 2024. The resident's care plan was last revised in December 2023, and there was no evidence of a care plan meeting for 2024. Both the MDS Coordinator and the Director of Nursing acknowledged the oversight, and the Administrator confirmed that care plan meetings should occur quarterly.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse to the state agency for two residents. Resident #19, who has a medical history including schizoaffective disorder and moderate cognitive impairment, reported to a surveyor that a Certified Medication Technician used inappropriate language when instructing them to take their medications. This allegation was reported to the Administrator by the surveyor, but the Administrator did not report it to the state agency, mistakenly believing that the presence of the survey team negated the need for immediate reporting. The Director of Nursing later confirmed that such allegations should be reported immediately, but no later than two hours after notification. Resident #21, with severe cognitive impairment and a history of antisocial personality disorder, reported feeling verbally abused by another resident. This allegation was also reported to the Administrator by a surveyor. However, the Administrator delayed reporting the incident to the state agency, citing previous experiences where in-person reports were made during surveyor visits. The report was eventually made two days later. These actions were contrary to the facility's policy, which mandates immediate reporting of abuse allegations to the appropriate agencies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident #57, who was admitted with a diagnosis of type two diabetes mellitus, did not have this condition addressed in their comprehensive care plan. Despite having a moderate cognitive impairment and receiving insulin, the care plan lacked measurable goals and interventions related to diabetes management. This oversight was confirmed by the MDS Coordinator, who acknowledged the importance of including diabetes in the care plan to guide staff in monitoring the resident's condition. Resident #66, admitted with Alzheimer's disease, hypertension, and mixed hyperlipidemia, did not have a comprehensive care plan developed at all. The MDS Coordinator and the Director of Nursing both confirmed that a care plan should have been completed within seven days of the MDS assessment reference date. The absence of a care plan for Resident #66 was not in line with the facility's policy, as confirmed by the Administrator, who stated that the MDS Coordinator was responsible for completing care plans.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily, as required by their policy. The policy, last revised on June 26, 2024, mandates that the Nurse Staffing Sheet be posted at the beginning of each shift, containing specific information such as the facility name, current date, resident census, and the total number and actual hours worked by different categories of nursing staff. However, during observations on October 7 and 8, 2024, the nurse staffing sheet was not found, and on October 9, 2024, the sheet was dated incorrectly. Interviews revealed that the medical records (MR) staff person was responsible for posting the nurse staffing sheet daily but admitted to not posting it on October 7, 2024, and posting the wrong sheet on October 8, 2024. The Director of Nursing expected the MR staff or social services to handle the posting, while the Administrator acknowledged that the posting was inconsistent. This lack of adherence to the policy resulted in the deficiency noted during the survey.
Failure to Maintain Cleanliness in Dining Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the main dining room, as evidenced by the presence of dead bugs and cobwebs in the windowsill. This deficiency was observed during multiple inspections, and a resident with intact cognition expressed concerns about the cleanliness of the dining room. The facility's policy on environmental cleaning aims to minimize exposure to potentially infectious microorganisms, yet the dining room's condition did not align with this policy. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities. A CNA mentioned that housekeeping services were not available daily, while a housekeeper stated that the dietary department was responsible for cleaning the dining room. The Dietary Supervisor confirmed this responsibility but was unsure about who should clean specific areas like window blinds and walls. The Director of Nursing and the Administrator both acknowledged the unsanitary conditions, with the Administrator noting similar issues in the lobby.
Failure to Complete PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a preadmission screening and resident review (PASARR) was completed for a resident who received new mental illness diagnoses. The facility's PASARR policy, last revised in July 2021, mandates the use of PASARR assessments to develop a care plan that reflects continuity from the resident's previous history of behaviors and placement. However, the medical record of the resident, who was admitted in January 2024 with a history of major depressive disorder and anxiety disorder, showed no evidence of a PASARR being completed after the resident was diagnosed with post-traumatic stress disorder and impulse disorder in April 2024. Interviews with facility staff revealed a lack of awareness and action regarding the need for a new PASARR following the resident's updated mental health diagnoses. The MDS Coordinator acknowledged that a new PASARR should have been completed, while the Director of Nursing mistakenly believed the mental illness diagnosis was pre-existing. This oversight indicates a failure to adhere to the facility's policy and ensure appropriate assessments were conducted in response to changes in the resident's mental health status.
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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