Pine Grove Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4359 Taft Avenue, Saint Louis, Missouri 63116
- CMS Provider Number
- 265828
- Inspections on file
- 15
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Pine Grove Manor during CMS and state inspections, most recent first.
The facility failed to follow physician orders and maintain accurate MAR/TAR documentation for multiple residents. A resident with anxiety and bipolar disorder did not receive a scheduled clonazepam dose even though an LPN documented it as given, and the controlled substance count confirmed the dose was not removed. Another resident with dementia, hemiplegia, and multiple comorbidities had numerous undocumented opportunities for scheduled lorazepam, behavior and side-effect monitoring, assistance with dressing, weekly skin assessments, and topical treatments across MAR, NAR, and TAR records. Two additional residents with diabetes, schizophrenia, and bipolar disorder had physician-ordered weekly skin assessments that were not documented on the ordered shifts, and the EMR assessment tab showed no current assessments corresponding to those orders.
The facility failed to provide adequate ADL care, including toileting, bathing, and grooming, to several residents. A resident who was severely cognitively impaired, incontinent, and fully dependent on staff was found at midday lying in urine-saturated linens with strong urine and body odor and open buttock wounds without dressings after not being checked since early morning, despite staff expectations for two-hour checks. Another cognitively intact resident with multiple comorbidities and incontinence was repeatedly observed with strong body odor, oily uncombed hair, and an unshaven face, reported that a cluttered shower room and lack of staff assistance prevented showers, and stated that poor hygiene worsened depression, while a CNA believed the resident managed hygiene independently. A third resident with severe cognitive impairment and an order for twice-weekly showers missed at least two scheduled showers and was observed with a strong sweat odor. Additionally, a cognitively intact resident dependent on staff for personal hygiene was repeatedly seen with long chin hairs despite expressing a desire for their removal, even though CNAs, LPNs, and leadership acknowledged staff were responsible for assisting with unwanted facial hair removal and grooming preferences.
Surveyors found that the facility did not complete activity assessments or develop care plan interventions for multiple residents with conditions such as dementia, bipolar disorder, stroke, MS, and schizophrenia, despite a policy requiring individualized activity programming. An outdated activity calendar was posted, but no group activities were observed over several days, and several cognitively intact residents reported that there were not enough activities, that they were bored, and that activity staff were insufficient. Some residents described doing nothing all day except for medical appointments or paying out-of-pocket for outings. Records for residents identified as needing 1:1 activities showed they were scheduled on specific days, yet there was no documentation of 1:1 activities being offered or provided, and observations confirmed these residents were not engaged in such activities. The Activity Director stated she had just started employment and had not yet created a current calendar or begun 1:1 activities, while the Administrator and DON stated they expected activities and 1:1 services to be provided and reflected in care plans.
The facility did not ensure that second-floor bathrooms were routinely cleaned, as required by its housekeeping policy. Surveyors observed multiple bathrooms with brown and yellow matter on toilet seats, strong bowel movement odors, unflushed toilets with urine and toilet paper, and shower floors with dark stains and hair. A cognitively intact resident with MS and insomnia reported that the bathrooms were dirty and not cleaned often enough, and that only one shower room was open and sometimes dirty. An LPN and a housekeeper confirmed that housekeeping was responsible for bathroom cleaning, with typically one housekeeper assigned to the floor and bathrooms expected to be cleaned each shift, while the Administrator and DON stated they expected bathrooms to be clean and maintained at least daily and as needed.
The facility failed to follow its own policies requiring that eligible residents be offered pneumococcal and annual influenza vaccines, receive education, and have all offers, consents, refusals, and administrations documented. Record review showed that two residents with COPD and other chronic conditions had no documentation of receiving, being offered, or being educated about the pneumococcal vaccine, and another medically complex resident had no documentation of receiving, being offered, or being educated about the influenza vaccine. The DON/IP acknowledged that all residents should be offered these vaccines if eligible and that all related actions should be recorded in the medical record, which did not occur.
A resident experienced a delay of up to nine minutes in receiving rescue breaths and oxygen during CPR because the Ambu bag mask was missing from the crash cart and staff were unable to operate the suction machine. Chest compressions were started promptly, but rescue breaths and suctioning were delayed due to missing supplies and lack of staff knowledge. When EMS arrived, staff stopped CPR before EMS was ready to take over, resulting in a lapse in compressions. The resident, who had severe cognitive impairment and multiple medical conditions, expired as a result.
Staff failed to prime pre-filled insulin pens before administering insulin to two residents with diabetes and other health conditions. In both cases, LPNs administered insulin without following manufacturer guidelines for priming, and the DON confirmed that this step is necessary to ensure accurate dosing. The facility's policy did not address insulin pen use, contributing to these significant medication errors.
A resident with severe cognitive impairment and total dependence on staff was found with their long-sleeve shirt sleeves tied together at the wrists, restricting hand movement and constituting a physical restraint. Staff interviews confirmed the knot was intentional and not accidental, and there was no documentation or care plan directive for restraint use. Facility leadership was unable to determine who was responsible for tying the sleeves.
A resident with multiple chronic conditions and recent cellulitis did not receive prescribed wound care due to failure to transcribe physician orders into the electronic medical record. The resident's wounds were observed without dressings or compression socks, and staff interviews revealed a lack of awareness and responsibility for entering and implementing the wound care orders. The Wound Doctor confirmed that his treatment orders were not followed.
The facility did not maintain safe water temperatures in resident rooms on the North and South halls, with temperatures ranging from 141 to 153 degrees Fahrenheit, exceeding the safe range of 105-120 degrees Fahrenheit. This affected 16 out of 31 sampled residents, posing a risk of scalding and burns. The Maintenance Director adjusted water heater temperatures based on resident complaints about cold water without verifying actual room temperatures. The facility's Safety of Water Temperatures Policy was not effectively implemented. Staff, including the Maintenance Director, DON, and Corporate Regional Nurse, were unaware of the high temperatures and used inappropriate methods for temperature checks. Residents with cognitive impairments and mobility issues were at increased risk.
The facility failed to provide meaningful activities or one-on-one activities for residents dependent on staff for their needs. The activity calendar showed limited variety, primarily focused on bingo and cards. Residents expressed dissatisfaction, and the Activities Director confirmed the lack of a regular activities program. The AD had limited formal training and was the only one responsible for activities, leading to the deficiency identified.
The facility failed to ensure the activity program was directed by a qualified professional. The Activity Director had not received formal training and had not started the required state-approved course, despite being enrolled since September 2023. The facility's job description required specific qualifications that the current Activity Director did not meet.
The facility failed to ensure the ice machine in the main kitchen had an air gap between the drain pipe to prevent back siphonage. Observations showed a gray plastic tube extending from the ice machine into a PVC drain pipe connected to the floor drain without an air gap. The Dietary Manager and Administrator were aware of the requirement but did not ensure compliance.
The facility failed to follow infection control standards during perineal and wound care for several residents. Staff did not perform proper hand hygiene or change gloves appropriately, increasing the risk of cross-contamination and infection. Interviews confirmed that facility policies were not adhered to, leading to these deficiencies.
The facility failed to complete pre and post dialysis assessments and did not maintain an accurate care plan for a resident requiring dialysis services. The dialysis communication forms were often incomplete, and the facility did not consistently document or follow up on the resident's assessments.
Failure to Follow Physician Orders and Accurately Document Medications and Skin Assessments
Penalty
Summary
The facility failed to ensure physician orders were followed and that services met professional standards of quality, as evidenced by multiple documentation and administration errors for several residents. One cognitively intact resident with anxiety, depression, and bipolar disorder had an order for clonazepam 0.5 mg to be given every evening at 4:00 p.m. The March MAR showed clonazepam documented as administered on a specific date at 4:00 p.m., but the controlled drug administration record showed the last actual administration occurred the previous day and that 11 tablets remained. The resident reported not receiving the clonazepam dose on that date, stated they informed night shift staff, and was told the medication was documented as given. Observation of the narcotic box with an LPN confirmed 11 tablets remained, and the LPN stated they thought they had given the dose but must have signed it off in the electronic record without actually administering it. Another resident with dementia, hypertension, hyperlipidemia, dysphagia, seizures, depression, hemiplegia, and major depressive disorder had multiple active orders, including scheduled lorazepam oral concentrate for anxiety every six hours, behavior and side-effect monitoring every shift, assistance with dressing and undressing every shift, weekly skin assessments, and topical anti-itch lotion and barrier cream. Review of the MAR and nurse’s administration record for February showed numerous blank entries where lorazepam doses, behavior observations, side-effect monitoring, and assistance with dressing were ordered but not documented, with missed documentation across dozens of opportunities. The treatment administration record for the same period also contained blank entries for weekly skin assessments and for the ordered topical anti-itch lotion and barrier cream, again with multiple missed documentation opportunities. Similar gaps continued into March, with additional blank entries for lorazepam administration, weekly skin assessments, and topical treatments. Two additional residents with diagnoses including diabetes, hearing loss, schizophrenia, dementia, and bipolar disorder had physician orders for weekly skin assessments on specified shifts. For one cognitively intact resident, the March MAR showed weekly skin assessments ordered on Wednesday night shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab predated those dates. For another resident with moderately impaired cognition, the March MAR showed weekly skin assessments ordered on Monday evening shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab also predated those dates. In an interview, the Administrator and DON stated they expected weekly skin assessments to be completed and documented in both the assessment tab and MAR when ordered, and that medications should be administered per physician orders with documentation of reasons and physician notification when not administered.
Failure to Provide Adequate ADL, Hygiene, and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate activities of daily living (ADL) care, including toileting, bathing, and personal hygiene, to multiple residents. One resident with severe cognitive impairment, hemiplegia, and dependence on staff for toileting, bathing, dressing, and personal hygiene was observed in bed at midday with a strong urine and body odor. When CNAs turned the resident, the brief, two quilted bed pads, and fitted sheet were saturated with urine, and the resident had open wounds on both buttocks without dressings. A CNA reported last checking the resident around 8:00 A.M. and stated they did not want to disturb the resident due to sleep and frequent pain, while nursing staff and the DON stated incontinent residents were expected to be checked and repositioned every two hours. Another resident, cognitively intact but with a history of stroke, dementia, diabetes, kidney failure, Parkinson’s disease, and myasthenia gravis, required partial to moderate assistance with bathing, personal hygiene, and toilet hygiene and was frequently incontinent of bladder and occasionally of stool. This resident was repeatedly observed in bed with strong body odor, uncombed oily hair, and an unshaven face with approximately half an inch of facial hair. The resident reported being willing to walk with a walker to the shower room but described the shower room as usually cluttered with equipment, which he could not move, and stated that staff did not help him get set up in the shower despite his requests. A CNA stated the resident “did his own thing,” was not known to need help with showers, and provided his own care, while the DON stated all residents required staff assistance with hygiene and were expected to be clean, dry, and odor free. A third resident with severe cognitive impairment, type 2 diabetes, schizophrenia, and cerebral palsy had a care plan indicating an ADL self-care performance deficit and a need for maximum staff assistance with personal hygiene. The MAR showed an order for showers twice weekly on the evening shift, but two scheduled showers in the review month were not documented as given, and the resident was observed on two occasions with a strong sweat-like odor. Additionally, a cognitively intact resident with type 2 diabetes, hearing loss, and schizophrenia, care planned as dependent on staff for personal hygiene and oral care, was observed multiple times with long white curly hairs on the chin. This resident stated a desire to have the chin hairs removed. Nursing and CNA staff, as well as facility leadership, acknowledged that both CNAs and LPNs could assist with removal of unwanted facial hair and that staff should ask residents about grooming preferences, but this assistance had not been provided.
Failure to Provide Individualized Activities and Scheduled 1:1 Programming
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assess residents’ activity preferences and to provide an ongoing activity program consistent with those preferences, as well as a failure to provide scheduled 1:1 activities to certain residents. The facility’s Activities Program policy, dated 6/2020, stated that the facility would provide an activity program designed to meet residents’ needs, interests, and preferences, with assessments completed within seven days of admission and individualized care plans developed and implemented. Observations on multiple days showed Mardi Gras decorations and an outdated February activity calendar posted, but no activities were observed being provided to residents at various times on several dates. The Activity Director reported that her first day was during the survey period, that the March activity calendar had not yet been created, and that she expected activities to be scheduled and calendars distributed and posted. Multiple residents who were cognitively intact and had various diagnoses reported that there were not enough activities and that they were bored. One resident with anxiety, depression, bipolar disorder, schizophrenia, and PTSD stated there were no activities taking place, that the previous Activities Director had left about two weeks earlier, and that the resident paid for a car ride to a store just to get out of the facility. Another resident with stroke, dementia, diabetes, kidney failure, and depression reported doing nothing all day except going to dialysis, expressed interest in puzzles, and recalled that the facility previously had a small bus for outings. Additional residents with diagnoses including diabetes, hearing loss, schizophrenia, multiple sclerosis, insomnia, hypertension, anemia, dementia, and bipolar disorder similarly stated that there were not enough activities, that there were not enough activity staff, and that they were bored most of the time. For several of these residents, record review showed no activity assessments and no care plan documentation related to activity participation or preferences, despite the facility’s policy and the Administrator and DON’s expectation that care plans reflect activity preferences. The survey also found that residents identified by the facility as needing 1:1 activities were not receiving them. A facility 1:1 Activity List showed three residents scheduled for 1:1 activities on specific days of the week, but their medical records contained no documentation of activities offered or provided. These residents had significant cognitive and neurological conditions, including dementia, bipolar disorder, hypertension, malnutrition, Alzheimer’s disease, stroke, hemiplegia, seizure disorder, anxiety disorder, aphasia, mild cognitive impairment, malnutrition, and Rett’s syndrome. Observations of these residents throughout the survey period showed them not engaged in any 1:1 activities. The Activity Director acknowledged that she had not started conducting 1:1 activities for residents on the 1:1 list, and the Administrator and DON stated they expected 1:1 activities to be provided to residents determined to benefit from them.
Failure to Maintain Clean and Sanitary Second-Floor Bathrooms
Penalty
Summary
The facility failed to maintain clean and sanitary second-floor bathrooms in accordance with its housekeeping policy, which requires all rooms to be kept clean and as free as possible of germs and other contaminating agents at all times. Surveyor observations on 3/9/26 showed that the toilet in the bathroom by the emergency exit door had brown and yellow matter on the seat with a strong bowel movement odor, the shower room floors had various dark stains and small hairs on the shower floor, and the toilet seat in the shower room had brown matter smeared on it. The bathroom across from the nurse's station also had a strong bowel movement odor, a dirty toilet seat with dark matter smeared on it, and toilet paper with a brown substance in the bowl. On 3/12/26, further observations of the same area showed the shower room toilet unflushed with toilet paper and urine in and on the toilet, and the shower floor with hairs and dark matter stains. Later that day, the shower room toilet again had brown smears and a strong bowel movement odor, with hair and dark matter stains on the shower floor. A cognitively intact resident with multiple sclerosis and insomnia reported that the second-floor bathrooms were dirty, not cleaned often enough, and that only one shower room was open and sometimes dirty. An LPN stated that bathrooms were expected to be clean but believed there were not enough housekeeping staff, and a housekeeper reported that normally one housekeeper is assigned to the second floor and that bathrooms are expected to be cleaned each shift. The Administrator and DON stated they expected bathrooms to be clean to prevent infection control issues and that housekeeping staff were responsible for cleaning bathrooms at least once daily and as needed.
Failure to Offer and Document Pneumococcal and Influenza Vaccinations for Eligible Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal and influenza vaccination policies. The facility’s written policies, last revised in June 2020, require that all eligible residents be offered pneumococcal and annual influenza vaccines, receive education on benefits and potential side effects, and that informed consent or refusal, as well as vaccine administration, be documented in the medical record. Record review showed that these steps were not followed for several residents, despite the policies specifying that refusals and any education provided must be documented. For one resident with heart failure, COPD, and kidney disease, and another resident with COPD and high blood pressure, there was no documentation that the pneumococcal vaccine was received, offered, or that vaccine education was provided. For a third resident with kidney disease, Parkinson’s disease, Myasthenia Gravis, diabetes, and bladder cancer, there was no documentation that the influenza vaccine was received, offered, or that vaccine education was provided. During interview, the DON/IP confirmed that all residents should be offered influenza yearly and pneumococcal vaccine if eligible, and that all offers, refusals, education, and administrations should be documented in the medical record, which did not occur for these residents.
Failure to Provide Effective CPR Due to Missing Equipment and Staff Incompetency
Penalty
Summary
The facility failed to provide effective cardiopulmonary resuscitation (CPR) to a resident who was identified as a full code, resulting in a delay of up to nine minutes before rescue breaths and oxygen could be administered. When the resident stopped breathing and had no pulse, the DON initiated chest compressions, but no rescue breaths were given initially because the Ambu bag mask was missing from the crash cart. Staff searched for the necessary equipment, with one LPN retrieving the mask from the nurse's desk and another attempting to set up the oxygen tank but unable to locate the key immediately. The oxygen was eventually connected, but only after a delay due to the missing mask and difficulty finding the key. During the code, staff also attempted to use the suction machine to clear the resident's airway, as the resident had significant secretions and a history of dysphagia and aphasia. However, staff were not knowledgeable about operating the suction machine, and it was never successfully used on the resident. The crash cart checklist had been marked as complete, but the required mask was not present at the time of the emergency, indicating a failure in equipment checks and readiness. The AHA guidelines and facility policy required rescue breaths and suctioning as part of CPR, but these were not provided in a timely manner due to missing supplies and lack of staff competency with the equipment. Additionally, when EMS arrived, staff stopped CPR before EMS personnel were ready to take over, resulting in a lapse in compressions. EMS had to ask if CPR was still needed and then resumed compressions upon entering the room. The resident, who had severe cognitive impairment and multiple medical diagnoses including sepsis and pressure ulcers, ultimately expired. The deficiency was identified through observation, interviews, and record review, and was determined to be at the immediate jeopardy level due to the failures in emergency response, equipment availability, and staff competency.
Failure to Prime Insulin Pens Results in Significant Medication Errors
Penalty
Summary
Staff failed to ensure residents were free from significant medication errors by not priming pre-filled insulin pens before administering insulin to two residents. For one resident with diabetes, kidney disease, obesity, and other conditions, an LPN administered insulin aspart without priming the pen, contrary to manufacturer guidelines that require priming to ensure accurate dosing. The LPN was unable to confirm whether the pen was primed prior to administration. The resident's care plan included monitoring for complications related to diabetes, but the insulin was given while the resident was eating, and the necessary step of priming was omitted. For another resident with diabetes, kidney disease, and additional diagnoses, a different LPN also failed to prime a Basaglar KwikPen before administering the prescribed insulin glargine. The LPN admitted to not priming the pen, despite manufacturer instructions and facility expectations to do so. The DON confirmed that priming is necessary to avoid administering air instead of the correct insulin dose. The facility's insulin administration policy did not specifically address the use of insulin pens, contributing to the medication errors observed.
Resident Found with Restrictive Clothing Used as Physical Restraint
Penalty
Summary
A deficiency occurred when a resident was found with the sleeves of their long-sleeve shirt tied together at the wrists, restricting the use of their hands and limiting freedom of movement. This action constituted the use of a physical restraint, as defined by the facility's own policy, which prohibits restraints unless necessary to treat a specific medical symptom and only after less restrictive interventions have failed. There was no documentation or physician order for the use of any restraint for this resident, nor was restraint use addressed in the resident's care plan. The resident involved had severe cognitive impairment, was rarely or never understood, and was totally dependent on staff for all activities of daily living. The resident had a history of non-traumatic brain dysfunction, hemiplegia, malnutrition, and anxiety disorder, and exhibited behavioral symptoms such as agitation, resistance to care, and repetitive movements like rubbing the scalp. Staff interviews confirmed that the resident could not have tied the sleeves themselves and that the knot was intentional, not accidental. The resident was unable to communicate what had happened and did not appear to be in distress at the time of discovery. Multiple staff, including CNAs and LPNs, reported that they were unaware of how or when the sleeves were tied, and no one took responsibility for the action. The facility's leadership, including the Interim Administrator and DON, acknowledged that it was never determined who tied the resident's sleeves. The care plan did not include any interventions involving restraints, nor did it address the resident's repetitive behaviors. The incident was identified through observation, interview, and record review, confirming a failure to protect the resident's right to be free from physical restraints.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care treatment orders for a resident were appropriately transcribed and implemented according to physician instructions. The resident, who had multiple diagnoses including peripheral vascular disease, diabetes, and a recent diagnosis of cellulitis, was assessed by the Wound Doctor, who ordered daily dressing changes and specific wound care interventions for venous insufficiency ulcers on both lower legs. However, these orders were not transcribed into the electronic Physician Order Sheet (ePOS) or the Medication Administration Record (MAR), and there was no documentation of the wounds in the resident's care plan. Observations revealed that the resident had visible wounds on both legs, which were not covered with dressings or compression socks as ordered. The resident reported having wounds for one to two months and stated that a doctor had prescribed medication nine days prior, but the treatment had not been received. Interviews with staff indicated confusion regarding responsibility for transcribing and implementing physician orders, with the desk nurse responsible for order entry but failing to transcribe the wound care orders into the electronic medical record. The Director of Nursing was unaware of the new wound care orders, and the LPN involved stated that only an order for the resident to be seen by the Wound Doctor had been entered. The Wound Doctor confirmed that he expected his orders to be followed and that the treatments he prescribed had not been administered. This sequence of events resulted in the resident not receiving necessary wound care as ordered by the physician.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free of accident hazards by not ensuring safe water temperatures in resident rooms on the North and South halls. The hot water temperatures in the resident room bathrooms were found to be between 141 to 153 degrees Fahrenheit, significantly exceeding the safe range of 105-120 degrees Fahrenheit. This deficiency was identified during a survey where 16 out of 31 sampled residents were affected by the excessively high water temperatures, posing a risk of scalding and burns. Observations revealed that the Maintenance Director had been adjusting the water heater temperatures in response to resident complaints about cold water, without verifying the actual water temperatures in the rooms. The facility's Safety of Water Temperatures Policy, which mandated water temperatures to be maintained within a safe range to prevent scalding, was not being effectively implemented. Residents with varying levels of cognitive impairment and mobility were exposed to dangerously high water temperatures, as evidenced by specific examples such as Resident #49, Resident #14, Resident #12, and Resident #15, among others. Interviews with staff members, including the Maintenance Director, Director of Nursing, and Corporate Regional Nurse, highlighted a lack of awareness regarding the high water temperatures and the inappropriate use of a laser thermometer for temperature checks. The report also noted that residents who wandered and had access to the bathrooms were at increased risk of being harmed by the hot water. The deficiency was classified as an immediate jeopardy (IJ) level K violation, indicating a serious threat to resident safety due to the failure to maintain safe water temperatures in the facility.
Lack of Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities or one-on-one activities for residents dependent on staff for their needs. The activity calendar showed a limited range of activities, primarily focused on bingo, cards, and occasional parties. Residents expressed dissatisfaction with the lack of variety and meaningful engagement in the activities offered. The Activities Director (AD) confirmed that most activities were self-governed, and there was no regular activities program in place. The AD also mentioned that she was the only one responsible for activities and had limited formal training. Resident #27, who was cognitively moderately impaired and had a history of schizophrenia, heart disease, stroke, and cancer, expressed a desire for outdoor activities and Bible study, which were not provided. Resident #5, who was cognitively intact and had diagnoses of diabetes, anxiety, depression, and schizophrenia, did not participate in activities due to the lack of variety and choices. Resident #28, who was also cognitively intact and had schizophrenia, expressed a similar sentiment, stating that the facility only offered bingo, which did not interest them. Resident #33, who had cancer and schizophrenia, also reported a lack of activities beyond bingo. The AD's work hours were limited to weekdays, and there were no structured activities on weekends. The AD relied on a resident volunteer to help with activities, and there was no documentation of one-on-one activities for residents. The Administrator acknowledged that the AD lacked formal training and that resident activities should be specific to their preferences and documented in progress notes. The facility's failure to provide a diverse and meaningful activities program led to the deficiency identified in the report.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activity program was directed by a qualified professional. The Activity Director, who had been employed at the facility for about two years and transferred to the activity program a year ago, had not received any formal training on how to run an activity program. Although she was enrolled in a state-approved activities director course, she had not started the program yet. The Administrator confirmed that the Activity Director did not have any formal training and had been enrolled in the class since September 2023 but had not started the classes because the facility wanted to see if she would remain consistent with the activity program. The facility's job description for the Activity Director required a high school diploma, completion of a state-approved activities director course, and one year of experience in a resident activities program in a healthcare setting, which the current Activity Director did not meet.
Ice Machine Lacks Required Air Gap
Penalty
Summary
The facility failed to ensure the ice machine in the main kitchen had an air gap between the drain pipe to prevent back siphonage. Observations on multiple dates showed a gray plastic tube extending from the back of the ice machine into a white PVC drain pipe, which was connected to the floor drain without an air gap. The area where the gray tubing was inserted into the PVC drain pipe was covered with dirt and debris. This deficiency had the potential to affect all residents who consumed drinks with ice, given the facility's census of 55 residents. During an interview, the Dietary Manager acknowledged awareness of the requirement for an air gap but was unaware that the ice machine did not have one. The Administrator also confirmed the expectation for an air gap to be present at the ice machine. The facility's Air Gap Policy for Ice Machine Draining Pipe outlined the necessity of an air gap to prevent backflow contamination, but this policy was not adhered to in practice, leading to the observed deficiency.
Infection Control Deficiencies in Perineal and Wound Care
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection control during perineal care and wound care for several residents. For Resident #28, a Certified Medication Technician (CMT) improperly wiped the resident's anal area from top to bottom while the resident was standing, using the same wipe multiple times without turning it. The CMT admitted to not regularly providing personal care due to their primary task of administering medications. Similarly, Resident #35 received improper perineal care from a Certified Nurse Aide (CNA) who did not separate the labia while wiping from front to back. Both staff members failed to change gloves appropriately during the care process, increasing the risk of cross-contamination and infection. In another instance, Resident #258, who had a surgical wound, received wound care from a Registered Nurse (RN) who did not perform hand hygiene before changing gloves multiple times during the procedure. The RN removed and replaced gloves without washing hands, thereby compromising the sterility of the wound care process. Additionally, Resident #46, who had an ingrown toenail, was assisted by the same RN who failed to change both gloves and perform hand hygiene after assisting another resident. The RN handled treatment supplies and touched the resident's wounds without proper glove changes and hand hygiene, further risking cross-contamination. Interviews with staff, including the Director of Nursing (DON), confirmed that the facility's policies and procedures for hand hygiene and glove changes were not followed. The DON acknowledged that failing to change both gloves and perform hand hygiene could lead to cross-contamination or infection. The Administrator also expected staff to adhere to the facility's policies and procedures, which were not followed in these instances, leading to the deficiencies observed during the survey.
Failure to Complete Dialysis Assessments and Maintain Accurate Care Plan
Penalty
Summary
The facility failed to complete pre and post dialysis assessments and did not have an accurate care plan for a resident requiring dialysis services. The resident, who was cognitively intact and diagnosed with end-stage renal disease (ESRD), received dialysis at an outside facility. The care plan did not reflect the current dialysis site location, and there were multiple instances where the dialysis communication forms were incomplete or missing vital information. Specifically, on several dates, the dialysis center information and post-dialysis assessments were either blank or not documented, and there was no record of the resident refusing these assessments or the facility contacting the dialysis center to obtain the necessary information. Interviews with the facility staff, including a registered nurse (RN) and the Director of Nursing (DON), revealed that the expected protocol was for pre and post dialysis assessments to be completed and documented on the dialysis communication form. These assessments included checking the graft site, vital signs, and observing for any complications. However, it was noted that sometimes the resident forgot to take the communication form to the dialysis center, or the dialysis center did not return the form. Additionally, if the resident refused the assessment, it was supposed to be documented, but this was not consistently done. The Director of Nursing confirmed that the dialysis communication forms were often incomplete and that the facility's policies and procedures were not always followed. The Administrator also stated that he expected the staff to adhere to the facility's policies and procedures. The lack of proper documentation and adherence to protocols led to the deficiency in providing safe and appropriate dialysis care for the resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
