Failure to Obtain Physician Orders for Catheter Care
Summary
The facility failed to ensure that physician orders for a suprapubic catheter change and site care were obtained upon admission for a resident. This oversight was identified during a review of the resident's medical records, which showed no orders for catheter changes or site care from the time of admission until several months later. The resident, who was competent to make decisions, reported that the catheter had not been changed or cleaned since admission, and there were no follow-up appointments scheduled for the catheter change. Interviews with facility staff revealed that the admission process was incomplete, as the necessary assessments and orders for the resident's catheter care were not obtained. The Licensed Nurse responsible for the admission did not perform a physical assessment to observe the catheter, and the Director of Nursing confirmed that the admission process was lacking in ensuring necessary treatments were in place. The deficiency was acknowledged by the staff, indicating a need for improvement in the admission process to prevent such oversights.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment was found incapacitated and had a POA for HC activated, but no financial POA was listed. Facility staff assumed the family member with HC POA and a joint checking account would handle finances, instructed them to pursue Medicaid, and sent letters pressuring them over the unpaid balance and discharge-related action even though the family member said they were not the financial POA.
Failure to thoroughly screen a resident before admission led to a resident with documented agitation, combative behavior, and use of mittens being admitted without an in-person assessment. Pre-admission records showed PRN Lorazepam orders and safety measures from the transferring hospital, and the resident later became combative during the initial nursing assessment and was involuntarily discharged for safety reasons. The DON/CNO, admission director, and Administrator stated that clinical review was based on paperwork and that no one laid eyes on the resident before admission.
A facility disenrolled three residents and attempted to disenroll a fourth from Managed Medicare without clear resident or representative request, consent, or understanding. Staff told representatives that switching to traditional Medicare would improve coverage or therapy access in the SNF and that residents could switch back after discharge. Records showed no signed consent forms or other documentation supporting the plan changes, and the facility lacked written policies for assisting with coverage changes.
Two residents with ESRD were admitted and retained while receiving PD even though the facility did not have PD listed in its facility assessment or an approved PD program. Records showed nightly PD orders and treatment logs, and family members stated the facility provided PD daily and did not tell them it lacked the license to do so. The ADM stated nursing staff assisted with PD initiation and disconnection, while the DON stated the residents should not have been admitted for PD care.
Admission Agreement Included Improper Liability Waiver Language: The facility used an admissions agreement and Resident Handbook stating it would not be responsible for loss or damage to a resident's valuables, personal property, or money, and that no deductions or credits would be taken for such loss. Two residents had signed handbooks containing this language. The DON, corporate DON, and Administrator stated they were not aware the wording did not meet regulatory requirements.
Surveyors found that the facility’s admission and valuables policies contained language stating the facility would not be responsible for resident money or personal items above a set dollar amount and would not be liable for lost or stolen items except in limited circumstances, effectively requiring residents or their representatives to waive facility liability for personal belongings. Review of records for two residents showed that, although admission agreements were properly signed, required Resident Inventory Listing forms were not completed, contrary to the facility’s own personal property policy. The administrator reported that the staff member responsible for inventories had left and not been replaced and stated that corporate legal guidance was that the facility was not required to replace stolen or missing items, with replacement handled only on a case-by-case basis.
Resident Representative Directed Beyond Healthcare Authority
Penalty
Summary
The facility did not ensure that a resident representative stayed within the scope of the authority granted to them when handling a resident’s finances. The resident was admitted and signed an admission agreement indicating they would make their own financial decisions, with no other representative listed for incapacity. The resident’s BIMS later showed severe cognitive impairment, and two physician signatures documented incapacity, activating the resident’s POA for healthcare. The POA for healthcare was the resident’s family member, but there was no financial POA listed before incapacity. After the resident became incapacitated, Social Services discussed private pay and Medicaid with the family member and asked them to help with the resident’s finances. The family member stated they were not the financial POA and were only the healthcare POA, but they were instructed by Social Services to apply for Medicaid. The family member also reported using personal money toward the resident’s bill and feeling unsure what to do while trying to get help with the Medicaid application. The facility sent multiple letters to the family member regarding the outstanding balance and threatened discharge-related action if payment was not resolved. One letter stated the family member might end up providing care because another facility would be impossible to find without their cooperation for payment. The Nursing Home Administrator acknowledged the facility assumed the family member would be responsible for finances because they had a joint checking account and had written checks before, and also acknowledged the facility should have taken alternate routes when the family member was not performing the expected duties.
Failure to Thoroughly Screen Resident Before Admission
Penalty
Summary
The facility failed to thoroughly screen a resident prior to admission for one resident reviewed for admission, discharge, and transfers. Pre-admission records from the transferring hospital documented that the resident had neurologic reserve Lorazepam for clearly documented seizures or severe agitation, with PRN Lorazepam orders of 0.5 mg every four hours and 2 mg every 15 minutes as needed, and that the resident was using bilateral mittens, full side rails, and a bed alarm. After admission, the resident arrived with mittens on both hands and became combative during the initial nursing assessment, attempting to hit both nurses. The resident was later involuntarily discharged from the facility for safety reasons, with the discharge notice stating that the safety of individuals in the facility was endangered. The resident's wife stated that the facility was aware of the resident's behaviors before admission and that the resident was feisty, irritable, and combative with staff. The Acting DON/CNO stated that the facility had a team of three for admissions and did not always lay eyes on a person before admission, while the admission director stated that the clinical side was reviewed by nursing staff and that she left the clinical decision to the nursing facility. The Administrator stated that she and the prior DON reviewed the resident's paperwork, that RT reviewed residents for the respiratory unit, and that no one laid eyes on the resident prior to admission.
Unauthorized Medicare Plan Changes
Penalty
Summary
The facility failed to protect 4 of 4 residents’ rights to Medicare benefits by disenrolling three residents and attempting to disenroll a fourth from Medicare Managed Health Plans without their request, consent, knowledge, or complete understanding. The report states the facility also failed to develop written policies and procedures for assisting beneficiaries with changing health care coverage, including when the facility could assist with a plan change and the need for an attestation signed by the staff member who assisted with the enrollment change. For one resident, the representative said facility social services staff told them it was better to be on traditional Medicare while in the SNF and that the resident would be transferred back to Managed Medicare after discharge. The representative later received a letter from the Managed Medicare plan stating the resident had been disenrolled. A physician also stated the representative came in tears after being told by facility staff to disenroll from Managed Medicare and switch to traditional Medicare, then re-enroll later. For two other residents, representatives stated facility staff approached them about changing coverage and told them traditional Medicare would cover more therapy or that the resident could switch back after discharge. One resident said they did not know whether they consented, and the representative said they were not aware of the disenrollment until after it occurred. For the fourth resident, the resident stated the Managed Medicare plan notified the facility that coverage was ending and facility staff discussed a secondary insurance option, while the business office manager said the facility tried to assist the resident to switch to traditional Medicare. Review of the records showed no consent forms or other documentation supporting that the residents or representatives requested the changes.
Admission and retention of residents requiring PD without approved PD services
Penalty
Summary
The facility failed to ensure that two sampled residents received services in accordance with the facility’s capabilities and available resources when it admitted and retained residents who required peritoneal dialysis (PD) without having an established PD program and the necessary services to safely provide PD care as approved by the State Agency. The deficiency was identified through interview and record review and involved Resident 1 and Resident 2, both of whom had end stage renal disease (ESRD) and were receiving PD while residing in the facility. Resident 1 was admitted with ESRD and infection and inflammatory reaction due to PD. Records showed Resident 1 had the capacity to understand and make decisions and was receiving PD for ESRD. Orders documented PD treatments using Dianeal with 1.5% Dextrose and later 1.5% Dextrose Solution, followed by Extraneal, with nightly treatments beginning at 7 PM. Treatment logs and the MAR showed PD treatments were provided across multiple periods during the resident’s stay. Resident 2 was admitted with ESRD and dependence on renal dialysis. Records showed Resident 2 had intact cognitive skills and was receiving PD upon admission. Orders documented PD using 2.5% Dextrose solution with nightly treatments beginning at 7 PM, and the MAR and treatment records showed PD treatments were provided during the resident’s stay. Family members stated the facility provided PD treatment every day and that they were not told the facility did not have the license to provide PD in the facility. Resident 1 stated she agreed to be admitted because she was told the facility could provide PD treatment and she did not know the facility was not allowed to provide PD. The facility assessment did not include PD services. The Administrator stated nursing staff assisted with initiating and disconnecting PD treatments and that the facility had the dialysis solutions and equipment on hand. The DON stated the facility should not have admitted the two PD residents and that providing PD service to them could put them at risk for infection and other complications. The facility policy required evaluation of the level of care needed prior to admission, and the CDPH guidance stated SNFs seeking to provide PD services must apply for approval of the optional service and notify CDPH before starting PD services.
Admission Agreement Included Improper Liability Waiver Language
Penalty
Summary
The facility failed to ensure its admission policy did not require residents and/or responsible parties to waive facility liability for loss or damage to personal belongings. Review of the Skilled Nursing Facility Resident Agreement showed the facility stated it would under no circumstances be held responsible for any loss or damage to valuables, personal property, or money brought to the facility, and that no deductions or credits would be taken from amounts due to the facility as a result of any loss suffered or damage done to residents' personal property. This language was identified in the agreement used by the facility. Record review showed this same language was present in the Resident Handbook signed by two residents, including one resident admitted to the facility and another resident admitted later. During interviews, the DON stated he/she was new and had not completed an admission contract with any residents and was not familiar with the policy. The corporate DON stated the admissions agreement was created at the corporate level and used at other facilities, and he/she believed it was appropriate but was not aware it did not meet regulatory requirements. The Administrator stated the admissions agreement was a standard contract used by the facility and said he/she had just been made aware of the wording about loss and/or damage to resident property and believed that statement was not agreeable to regulation.
Noncompliant Admission Liability Language and Missing Resident Property Inventories
Penalty
Summary
Facility staff failed to ensure that admission policies and documents complied with requirements regarding resident property and financial protections. Review of the facility’s undated "Cash and Valuables Policy Update" showed language stating the facility would not be responsible for any money or personal items exceeding a $40.00 limit. The admission agreement dated 02/2018 further stated the facility would not be liable for any resident items that were lost or stolen, except for items noted for replacement under state guidelines. These provisions effectively required residents and/or responsible parties to waive facility liability for loss or damage to personal belongings as a condition of admission, contrary to regulatory requirements that residents not be required to give up Medicare or Medicaid benefits or pay privately as a condition of admission, and that they be informed of what care the facility does not provide. In addition, the facility did not follow its own "Personal Property" policy dated 12/2024, which required that residents’ personal belongings and clothing be inventoried and documented upon admission and as items were replenished. Record review for two residents showed that, although admission agreements were signed and dated by the residents/responsible parties and a facility representative in April 2026, there was no documentation that staff completed a Resident Inventory Listing form for either resident. During an interview, the administrator stated that the staff person responsible for completing inventory lists had quit and had not been replaced, and acknowledged that inventory sheets for these residents could not be located. The administrator also reported that the corporate legal department advised that in Missouri the facility was not required to replace stolen or missing items, and that the policy stated the facility was not responsible for replacing missing or stolen items except on a case-by-case basis.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.