The violation involved Hydrochlorothiazide, a medication ordered for Resident 14 on September 20, 2025. The physician's order was specific: "Give one tablet by mouth one time a day for hypertension. Do not give if systolic blood pressure less than 100."
From September 21 through September 30, medication administration records showed the drug was "administered as ordered" every single day. But there was no documentation of the resident's blood pressure on any of those days.
The resident had moderate cognitive impairment and high blood pressure, according to quarterly assessment records dated in 2025. The care plan goal stated the resident would "remain free from signs and symptoms of hypertension."
Licensed Practical Nurse Z confirmed during an October 24 interview that blood pressure "would have to be checked prior to administration." The nurse read the physician's order aloud and acknowledged the medication was for blood pressure control.
But when LPN Z looked at the resident's vital signs records, the blood pressure readings weren't documented daily. The nurse explained that while nursing staff signed off on obtaining blood pressure readings, the Certified Medication Technician who actually administered the medication would be responsible for checking the blood pressure beforehand.
Nobody could confirm the checks were happening.
During an October 27 interview, the facility's Nurse Practitioner said she expected staff to obtain blood pressure readings before giving the medication. But she admitted uncertainty about whether staff were actually documenting the vital signs.
The Regional Nurse Consultant echoed this expectation during an October 28 interview, saying staff should take the resident's blood pressure before administering Hydrochlorothiazide. The consultant suggested blood pressure readings could be added to the medical record as supplemental documentation when obtained.
Corporate Nurse G told inspectors the same day that complete and accurate medical records were essential. Staff should document treatments and medications when administered, the nurse said.
The facility's Administrator said during an October 24 interview that he expected staff to follow facility policies and procedures.
The medication at the center of the violation is a diuretic commonly used to treat high blood pressure. Taking it when blood pressure is already low can cause dangerous drops in blood pressure, leading to dizziness, falls, and other complications.
The inspection also revealed problems with tube feeding documentation for another resident. Feeding records showed blank entries for required water flushes every four hours, with no explanation for the missing documentation.
The Registered Dietician told inspectors during an October 29 interview that she monitored whether residents were refusing food and tube feedings by checking administration records. If she saw a blank entry on the Treatment Administration Record, she couldn't determine whether the resident had received the feeding or refused it.
"If he/she was refusing, it should be documented," the dietician said.
The resident's care plan called for 150 milliliters of water flush every four hours, with a note that "resident will refuse at times." But the blank entries provided no indication of whether the flushes were given, refused, or simply not administered.
Both violations fell under federal regulations requiring nursing homes to ensure residents receive proper treatment and services. The inspection report classified the level of harm as "minimal harm or potential for actual harm" affecting few residents.
The medication safety violation represents a breakdown in the basic safety protocols that protect vulnerable nursing home residents from dangerous drug interactions and side effects. Federal inspectors completed their investigation on November 18, 2025, following complaints that triggered the unscheduled inspection.
Athene Nursing and Rehabilitation operates at 13995 Clayton Road in Town and Country, Missouri. The facility must submit a plan of correction to address the documented violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Athene Nursing and Rehabilitation from 2025-11-18 including all violations, facility responses, and corrective action plans.
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