Pine View Manor Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Stanberry, Missouri.
- Location
- 307 N Pineview Street, Stanberry, Missouri 64489
- CMS Provider Number
- 265506
- Inspections on file
- 17
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pine View Manor Inc during CMS and state inspections, most recent first.
Two cognitively intact residents engaged in a verbal argument after one made a rude, profane comment to a staff member and threatened to hit the other resident. One resident was taken back to their room while the other remained near the nurse’s station; about ten minutes later, the resident in a wheelchair went down the hall, turned into the other resident’s room despite an LPN telling them not to, and a physical struggle occurred, with both ending up on the floor. One resident sustained a scraped knee, a skin tear to the elbow, and a contusion with a large bruise and pain to the left ribs and chest wall, later confirmed in ER records. Staff acknowledged that resident‑to‑resident altercations are considered abuse and that 15‑minute checks are typically used afterward, but in this case no formal 15‑minute checks or one‑on‑one observation were implemented, and there was no formal protocol or documentation tool specifying or recording the frequency of monitoring, leading to the cited deficiency.
The facility failed to adhere to safe food storage practices, as dented and unlabeled canned foods were found in the dry storage area. Despite having a policy for food receiving and storage, there was no specific guideline for handling dented cans. Staff interviews revealed inconsistent practices in inspecting and storing deliveries, leading to the presence of 36 compromised cans, which posed potential contamination risks.
A facility failed to ensure proper infection control during medication administration and oxygen supply management. A CMT did not wear gloves or wash hands between fingerstick blood sugar checks for two residents with diabetes, contrary to facility policy. Additionally, a resident's oxygen tubing was not consistently dated or stored in a bag, as required. The facility's policies were not followed, leading to deficiencies in infection control practices.
A resident with COPD and non-Alzheimer's dementia was not assessed for self-administration of medication, despite expressing a desire to do so. The facility's policy requires an assessment by the interdisciplinary team to ensure safety and appropriateness, but no such evaluation was conducted. Interviews with staff revealed a lack of awareness regarding the necessity of this assessment, leading to a deficiency in care.
A facility failed to include a resident's supplemental oxygen usage in their care plan, despite having active orders for oxygen due to conditions like pneumonia and heart failure. Interviews with staff confirmed that care plans should address oxygen use, but this was not reflected in the resident's care plan, leading to a deficiency.
A resident with COPD experienced shortness of breath after physical activity, prompting a CNA to adjust the oxygen concentrator to 3 liters per minute, despite not being licensed to do so. Facility staff confirmed that only licensed personnel should adjust oxygen settings, and the CNA failed to report the resident's condition to a nurse.
A resident with a history of hypoxemia and other conditions required supplemental oxygen therapy, but the facility failed to specify the liters per minute (L/min) parameters in the orders. Staff monitored the resident's blood oxygen saturation and adjusted the oxygen flow, but noted the absence of specific L/min guidelines. The deficiency was identified as a failure to include these parameters, which are essential for proper respiratory care.
A resident with hypertension and severe cognitive impairment received metoprolol tartrate despite not meeting the prescribed blood pressure parameters. The facility's staff failed to document the resident's heart rate and administered the medication multiple times when it should have been held. Interviews with staff revealed a lack of adherence to physician's orders, leading to a significant medication error.
A resident with COPD and intact cognition was allowed to self-administer Flonase nasal spray, but the facility failed to ensure it was stored securely. The medication was left on the dresser, accessible to others, against the facility's policy. Staff interviews revealed inconsistencies in understanding the storage policy, with expectations ranging from bedside tables to bathroom cabinets.
The facility failed to ensure nurse aides received the required 12 hours of in-service training per year, as two CMTs did not meet this requirement. Their training records lacked sessions on dementia management, and the facility acknowledged missing records. A new Staff Development Director had been hired but had not yet started.
Failure to Prevent and Adequately Monitor Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse in the form of a resident‑to‑resident physical altercation following a verbal confrontation. The facility had policies on Abuse and Neglect and Resident‑to‑Resident Altercations that required staff to prohibit and prevent abuse, monitor residents for aggressive or inappropriate behavior toward others, review events with nursing leadership, and document interventions and their effectiveness. On the day of the incident, two cognitively intact residents engaged in a verbal argument at the nurse’s station after one resident made a rude, profane comment to a dietary aide about grapes. Another resident, who was independent with activities of daily living, heard the remark and told the first resident not to speak to staff that way. The first resident became angry and responded aggressively, including stating that he/she was going to hit the other resident one of these days. Following this verbal altercation, staff assisted one resident back to his/her room while the other remained seated near the nurse’s station with staff nearby. Approximately ten minutes later, staff who had been sitting with the resident near the nurse’s station went outside on break. During this period, the resident who had remained near the nurse’s station proceeded down the hallway in a wheelchair past the other resident’s room, then turned around and entered that room despite being told by an LPN not to go into the room. When the LPN arrived at the room, both residents were found on the floor. Accounts from the residents differed as to who initiated the physical contact, but both described a physical struggle in which they shoved each other and fell, with one resident reporting having lunged and the other reporting reaching toward the first resident. As a result of the altercation, one resident sustained physical injuries including a scraped left knee, a skin tear to the left elbow, and a red mark and contusion to the left rib and left chest wall, with pain to the left ribs and left knee documented in emergency room discharge instructions. Observation later showed a grapefruit‑sized bruise on the left rib area. Staff interviews confirmed that resident‑to‑resident physical altercations were considered abuse under facility practice and that typically 15‑minute checks were done after such incidents. In this case, neither resident was placed on one‑on‑one observation or formal 15‑minute checks after the altercation, and there was no formal protocol or documentation tool used to specify or record how often the residents should be monitored, despite instructions to staff to keep a close watch on them. This sequence of events and lack of structured monitoring following the initial verbal threat and subsequent altercation led to the cited deficiency for failure to protect a resident from abuse.
Failure to Maintain Safe Food Storage Practices
Penalty
Summary
The facility failed to maintain professional standards in food storage and handling, as evidenced by the presence of dented canned foods in the dry storage area. Observations revealed several compromised cans, including unlabeled and dented cans of various food items, which were not segregated from the usable stock. The facility's policy on food receiving and storage required safe handling practices, but there was no specific policy addressing dented canned foods. Interviews with staff, including the Certified Dietary Manager (CDM) and dietary aides, indicated a lack of consistent procedures for handling and removing dented cans, leading to their presence in the storage area. The CDM acknowledged the risks associated with dented cans, such as potential contamination and illness, but the facility did not have a designated area for storing such items. Staff interviews revealed inconsistent practices in inspecting and handling deliveries, with some staff unaware of the proper procedures for dealing with compromised cans. The Administrator and Director of Nursing Services (DNS) were also interviewed, with the DNS unaware of the risks posed by dented cans. Ultimately, 36 compromised cans were removed from the storage area, highlighting the facility's failure to adhere to safe food handling standards.
Infection Control Deficiencies in Medication Administration and Oxygen Supply Management
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, specifically during fingerstick blood sugar checks. A Certified Medication Technician (CMT) did not wear gloves while performing fingerstick blood sugar checks for two residents, one with type one diabetes mellitus and another with type two diabetes mellitus. The CMT also failed to wash hands between residents, which was against the facility's policy that required wearing gloves and hand hygiene when there was potential contact with blood. The CMT admitted to forgetting to wear gloves and not washing hands, and both the Director of Nursing Services (DNS) and the Administrator confirmed that the facility's policy was not followed. Additionally, the facility did not properly label and store oxygen supplies for a resident who used supplemental oxygen at night. The resident's oxygen tubing and nasal cannula were observed lying on the bed and hanging on the bed rail without being stored in a bag or dated, contrary to the facility's expectations. Interviews with staff revealed that night shift staff were responsible for changing and dating the oxygen tubing weekly, while day shift staff were to ensure the tubing remained clean. However, the tubing was not consistently dated or stored in a bag as required. The Administrator and other staff members confirmed that the facility's policy was for oxygen tubing to be dated and stored in a bag when not in use. Despite these expectations, observations showed that the policy was not consistently followed, leading to a deficiency in infection control practices related to the storage and labeling of oxygen supplies.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, who expressed a desire to self-administer medication, was assessed to determine if it was clinically appropriate for them to do so. The facility's policy on self-administration of medications requires an interdisciplinary team to assess a resident's mental and physical abilities to determine if self-administration is safe and appropriate. However, in the case of the resident with a history of chronic obstructive pulmonary disease and non-Alzheimer's dementia, no such assessment was conducted. The resident had a physician's order to keep Flonase at their bedside, but there was no documented evidence of an assessment for self-administration. Interviews with facility staff, including the MDS Coordinator, a registered nurse, and the Director of Nursing Services, revealed a lack of awareness and understanding of the requirement for an assessment before allowing a resident to self-administer medication. The MDS Coordinator believed that a physician's order was sufficient for a resident to keep medication at the bedside, while the RN was unaware of the need for an assessment. The Director of Nursing Services stated that staff should ensure a resident is capable of self-administering medication and document the assessment in the electronic medical record, but this was not done for the resident in question.
Deficiency in Care Plan for Supplemental Oxygen Use
Penalty
Summary
The facility failed to develop a care plan addressing the use of as-needed supplemental oxygen for a resident with a history of pneumonia and heart failure. The resident was admitted on June 19, 2023, and had active orders for two liters of supplemental oxygen via nasal cannula as needed for shortness of air and at bedtime for hypoxia. However, the resident's care plan did not include any information regarding the supplemental oxygen usage prior to May 31, 2024, which was during the survey. Interviews conducted during the survey revealed that the facility's Registered Nurse and Administrator both acknowledged that care plans should address a resident's use of oxygen, including the ordered flow rate, usage parameters, and whether it was used continuously or as needed. Despite these expectations, the care plan for the resident in question did not reflect these details, leading to the identified deficiency.
Unlicensed Personnel Adjusted Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that only licensed personnel adjusted the flow rate on an oxygen concentrator for a resident with chronic obstructive pulmonary disease (COPD). The resident, who had intact cognition and was receiving oxygen therapy, was observed with an oxygen concentrator set to deliver 2.5 liters per minute. After experiencing shortness of breath following physical activity, the resident activated their call light. A Certified Nurse Aide (CNA) responded and adjusted the oxygen concentrator to deliver 3 liters per minute, despite not being licensed to administer medications or adjust oxygen settings. Interviews with facility staff revealed that the CNA was aware that supplemental oxygen is considered a medication and that she was not authorized to change the oxygen concentrator settings. The Director of Nursing Services (DNS) and other staff confirmed that CNAs were not permitted to adjust oxygen concentrators and should report any issues to a nurse. The DNS acknowledged that the CNA did not report the resident's shortness of breath or the adjustment made to the oxygen concentrator. The facility's policy required that only licensed personnel administer medications, including oxygen therapy, as per physician orders.
Deficiency in Oxygen Therapy Due to Lack of Dose Parameters
Penalty
Summary
The facility failed to specify dose parameters for supplemental oxygen for a resident, leading to a deficiency in respiratory care. The resident, who had a medical history of hypoxemia, dystonia, torticollis, and pneumonia, was admitted to the facility and required oxygen therapy. The care plan indicated the use of humidified supplemental oxygen via nasal prongs at 2 liters continuously at night and as needed during the day. However, the order summary report for the resident's supplemental oxygen did not specify the liters per minute (L/min) parameters, only indicating that the oxygen should maintain blood oxygen saturation levels above 91%. Observations and interviews revealed that the resident's nasal cannula was often askew, and the oxygen concentrator was set at 2 L/min. Staff members, including a CNA and RN, were aware of the need to monitor the resident's blood oxygen saturation levels and adjust the oxygen flow as necessary. However, they noted the absence of specific L/min parameters in the orders, which should have been included to guide the administration of oxygen therapy. The RN mentioned that she would start with 2 L/min in the absence of specific parameters and monitor the resident's condition. Interviews with various staff members, including the DNS and the facility's administrator, confirmed that supplemental oxygen orders should include L/min parameters. The DNS acknowledged the issue and stated that they were awaiting a call back from the physician to update the order with the necessary parameters. The deficiency was identified as a failure to include L/min parameters in the supplemental oxygen orders, which is essential for ensuring proper respiratory care for the resident.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of metoprolol tartrate, a medication used for high blood pressure. The resident, who had a history of essential hypertension and severe cognitive impairment, was admitted with a physician's order for metoprolol tartrate 25 mg twice daily. The order included specific parameters to hold the medication if the resident's systolic blood pressure was below 120 mmHg, diastolic blood pressure was less than 60 mmHg, or if the heart rate was less than 60 beats per minute. However, the Medication Administration Record (MAR) showed that staff administered the medication multiple times despite the resident's blood pressure readings not meeting the required parameters, and without documenting the resident's heart rate. Interviews with Certified Medication Technicians (CMTs) revealed that they did not follow the physician's orders. CMT #4 and CMT #10 acknowledged that the resident's pulse was not documented, and the medication was given even when blood pressure parameters were not met. CMT #11 admitted to administering the medication without checking the resident's pulse and overlooking the blood pressure parameters. Registered Nurse (RN) #5 confirmed that the medication should not have been given when the systolic blood pressure was below 120 mmHg and expressed concern that the CMTs did not report the low blood pressure readings. The Consultant Pharmacist (CP) and the Director of Nursing Services (DNS) both stated that the medication should have been held when the parameters were not met. The DNS was unaware that the medication was administered against the parameters and that the heart rate was not documented on the MAR. The Administrator expected the physician's orders to be followed and for the physician to be notified if the parameters were not met. The failure to adhere to the physician's orders and the lack of proper documentation led to the significant medication error.
Failure to Securely Store Self-Administered Medication
Penalty
Summary
The facility failed to ensure the safe storage of medication for a resident who was permitted to self-administer Flonase nasal spray. The resident, who had intact cognition and a medical history of chronic obstructive pulmonary disease, had a physician's order allowing them to keep the Flonase at their bedside. However, the medication was observed on the resident's dresser, accessible to others, contrary to the facility's policy requiring self-administered medications to be stored in a secure place not accessible by other residents. Interviews with facility staff, including a CNA, CMT, RN, and the Director of Nursing Services, revealed inconsistencies in the understanding and implementation of the facility's policy on medication storage. The CNA and CMT acknowledged the medication was kept on the dresser, while the RN mentioned it should be stored on or in the bedside table. The Director of Nursing Services expected medications to be stored in a bathroom cabinet, and the Administrator expected them to be out of sight. The resident confirmed that no instructions were provided by the staff on how to store the medication securely.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training per year, as mandated by the Facility Assessment Tool. This deficiency was identified through interviews, record reviews, and an examination of the Facility Assessment Tool. Specifically, two Certified Medication Technicians (CMTs), hired in 2018 and 2019 respectively, did not meet the training requirements. CMT #3 attended only four in-services from June 2022 to June 2023, none of which included dementia management training. Similarly, CMT #10 attended only four in-services from December 2022 to December 2023, also lacking dementia management training. The records did not specify the number of in-service hours awarded for each session attended by these CMTs. The Administrator acknowledged the potential absence of complete in-service training records during an interview. It was noted that the facility had recently hired a full-time Staff Development Director (DSD), although the DSD had not yet commenced work at the facility. This situation indicates a lapse in maintaining adequate training records and ensuring compliance with the required in-service training hours, particularly in critical areas such as dementia management and abuse prevention.
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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