Abundant Acres Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Savannah, Missouri.
- Location
- 13277 State Route D, Savannah, Missouri 64485
- CMS Provider Number
- 265846
- Inspections on file
- 32
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 42 (2 serious)
Citation history
Health deficiencies cited at Abundant Acres Care And Rehab during CMS and state inspections, most recent first.
The facility did not have a policy or maintain records regarding staff CPR certification, resulting in several staff members lacking current certification and no clear way to identify who on shift was certified. Staff were not asked about CPR certification upon hire, and there was no list of CPR-certified personnel available, potentially affecting all residents who required CPR.
A facility failed to protect residents from physical abuse when two residents, both with severe cognitive impairments and behavioral issues, were involved in a physical altercation. One resident struck the other, resulting in minor injuries. The incident was witnessed by a CNA who intervened, and an RN provided first aid. The facility's policy on abuse prevention was not effectively implemented, leading to this deficiency.
A resident with a history of inappropriate sexual behavior was found in another resident's room, engaging in non-consensual contact. The resident had a history of sexual behaviors and cognitive impairment, contributing to the incident. The affected resident was asleep and had severe cognitive impairment, highlighting a failure in monitoring and protection.
The facility failed to install backflow preventers on all shower hoses, risking contamination of the potable water supply. Observations revealed missing preventers on hoses in two shower rooms and a resident's room. The Maintenance Supervisor was unaware of the requirement, affecting the safety of 47 residents.
The facility failed to provide the SNF Advance Beneficiary Notice (ABN) to three residents who continued to stay after their Medicare Part A benefits ended. The Business Office Manager and Administrator were unaware of the requirement to issue the SNF ABN, resulting in residents not being informed of their potential financial responsibility for services not covered by Medicare.
The facility failed to maintain a clean and safe environment, with observations of cobwebs, scuffed walls, broken blinds, and mold-like substances on vents. The SCU dining room had dusty blinds and flies landing on residents. The Administrator noted maintenance and housekeeping responsibilities, but no cleaning policy was provided.
The facility failed to conduct necessary background checks for new hires, neglecting to verify the CNA Registry and FCSR for six staff members, contrary to its policy. The Business Office Manager, new to the role, lacked complete employee records due to a recent county takeover and was unaware of the required agencies for background checks. The Administrator confirmed the need for documented checks, indicating a systemic hiring process failure.
Two residents with cognitive impairments and incontinence did not receive necessary perineal care and repositioning every two hours as required. Observations showed that one resident was left in a saturated brief for over three hours, while another was not repositioned or provided care for a similar duration. Interviews with CNAs confirmed the lack of timely care, despite expectations from the LPN, DON, and Administrator.
The facility failed to provide an ongoing program of activities tailored to meet the individual interests and well-being of three residents. A resident with significant cognitive loss was observed without engagement in preferred activities, despite a care plan emphasizing structured activities. Another resident expressed dissatisfaction with limited activities and was often found idle or walking the halls. A third resident, with severely impaired cognition, was observed lying in bed without staff interaction. The Activity Director, new to the role, struggled to provide adequate activities due to a lack of training and support.
The facility failed to ensure call lights were accessible to two residents, both with cognitive impairments and dependent on staff for ADLs. Observations showed call lights out of reach, either on the floor or behind curtains. Staff interviews confirmed the expectation for call lights to be within reach, but this was not consistently practiced.
The facility failed to address significant weight loss in three residents and did not provide adequate snacks and fluids to residents in the SCU. A resident lost 17.6 pounds over 180 days, another lost 11.07% of their body weight, and a third complained of hunger without receiving snacks. Observations showed residents without access to snacks or drinks, and empty water pitchers. The staff acknowledged the lack of snack and drink offerings, and there was no specific person responsible for entering weight data into the EMR.
The facility failed to provide proper respiratory care for three residents, with issues such as undated oxygen tubing, empty humidified bottles, and dusty concentrator filters. Despite physician orders and facility policies, staff did not maintain the equipment, leading to discomfort for residents. Interviews revealed a lack of awareness and adherence to maintenance protocols.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist, affecting two residents with significant cognitive and mental health conditions. Both residents were on multiple medications, but their records showed no medication regimen reviews for 2024, highlighting a lapse in monitoring unnecessary medications and drug irregularities.
The facility failed to ensure the Dietary Manager had the necessary competencies and skills for food and nutrition services, as the DM lacked dietary certification and was not enrolled in training. The Administrator was aware of this deficiency, and the facility did not provide a policy on DM qualifications. The facility census was 47 residents.
The facility failed to provide pureed foods with the appropriate texture and consistency, as observed during a lunch meal where the tuna casserole and tortellini were not smooth and contained particles. The Dietary Manager did not follow recipes or measure ingredients, leading to inconsistencies. Interviews confirmed that pureed foods should be smooth, but the facility lacked a policy for their preparation.
The facility failed to maintain sanitary conditions in its kitchen and food storage areas, affecting all residents receiving food. Observations showed unsanitary conditions, including dirty equipment, incomplete logs, and improperly stored food. Staff interviews revealed inconsistencies in food safety practices and unclear responsibilities, leading to these deficiencies.
The facility failed to establish an effective antibiotic stewardship program, lacking protocols for optimizing infection treatment and monitoring antibiotic use. New staff, including the Infection Preventionist and DON, were unable to provide data on current antibiotic use or infection trends, highlighting a significant gap in infection control practices.
The facility failed to provide dementia and behavior training for staff, affecting residents with cognitive and behavioral issues. A resident with severe dementia was inappropriately teased by a CMT, while another resident at risk for wandering was not offered snacks or drinks. Staff lacked awareness of residents' conditions and had not received recent dementia education.
The facility failed to meet professional standards of care for three residents. A resident with severe shoulder pain did not receive a physician-ordered MRI, preventing further pain management. Another resident with cognitive loss and multiple diagnoses did not have a scheduled ENT consultation after an ear incident. Additionally, a resident with severe cognitive loss was prescribed Lorazepam without a stop date, contrary to medication management protocols.
The facility failed to manage its resources effectively, resulting in non-payment to staffing agencies and suspension of services. This, coupled with inadequate communication during a transition of ownership, caused significant stress and anxiety among residents and families. Many were unaware of who the current administrator was or who to contact with concerns, leading to feelings of anger and frustration. The lack of transparency and communication exacerbated these issues, particularly affecting residents with cognitive impairments.
The facility failed to communicate effectively with residents and their families during a transition to a new operator, leading to stress and anxiety. Residents and family members were left to rely on rumors for information, causing significant distress about future care and living arrangements. Despite expectations for leadership to address concerns, the administrator did not acknowledge the stress experienced by residents.
The facility failed to offer residents and their families a choice of pharmacy when the primary pharmacy was changed to Pharmacy B, affecting nine residents. Despite the facility's policy to support resident choice, several residents and their families were unaware of the change and were not given a choice. Interviews with staff revealed a lack of communication and responsibility regarding the change.
The facility failed to notify residents and families of Resident Council Meetings and did not honor requests for staff and family attendance, affecting several residents. A resident council president was informed of a meeting about ownership transition only 30 minutes prior, causing anxiety and insufficient preparation time. Other residents and family members were either not informed in time or unable to attend, leading to confusion and distress among residents with cognitive impairments.
The facility did not refund personal funds and provide a final accounting to six residents within 90 days of discharge. This issue was identified through interviews and record reviews, and the facility lacked a policy on refunding resident funds.
The facility was found to have a deficient call system in resident bathrooms and bathing areas. The system failed to allow residents to communicate with staff effectively, as it did not relay calls directly to staff or alert them in the corridor. This issue was identified through observation and interviews, with the facility census at 47 residents.
The facility did not refund personal funds to six residents within the required 90 days after discharge, with balances ranging from $399.00 to $3,321.10. The Director of Operations was aware of the 30-day refund requirement but was unsure why the corporate accounting department had not processed the refunds. The facility also lacked a policy on refunding resident funds.
The facility failed to provide drinks consistent with residents' needs and preferences, affecting four residents. A resident with moderate cognitive impairment reported infrequent water provision, and observations showed signs of dehydration. Another resident, severely cognitively impaired, had a warm water pitcher unchanged throughout the day. A third resident had dry, cracked lips, and a fourth resident reported not receiving water that day. Staff interviews revealed inconsistencies in water provision practices.
The facility's call system was found to be deficient, with call lights in several rooms failing to activate indicator lights above doors or on the call light board. Notifications appeared only at the central nurses' station for the open unit, while the secure unit relied on staff presence to relay alerts. Staff interviews confirmed the system's prolonged malfunction, and the Director of Operations was unaware of the issue.
A resident with severe cognitive impairment was found with multiple injuries, including bruising and a skin tear, which were not reported to the appropriate authorities in a timely manner. Despite documentation by an LPN and observations by other staff, the injuries were not reported to the DON or Administrator immediately, leading to a delay in notifying the state agency beyond the required two-hour window.
A resident with severe cognitive impairment was found with bruises and a skin tear, but the facility failed to conduct a thorough investigation. Key staff were not interviewed, and documentation was incomplete, leading to a deficiency in addressing the injuries.
Failure to Ensure Availability of CPR-Certified Staff
Penalty
Summary
The facility failed to ensure the availability of staff who could provide cardiopulmonary resuscitation (CPR) prior to the arrival of emergency medical personnel, as required by physician orders and residents’ advance directives. There was no policy in place regarding staff CPR certification or maintaining a list of staff currently on shift who were CPR certified. Review of employee files revealed that several staff members, including RNs, CNAs, and CMTs, did not have evidence of current CPR certification in their files. Interviews with staff indicated that some had expired certifications, some were not certified at all, and none were asked about their CPR certification status upon hire. Staff also reported not knowing which coworkers on shift were CPR certified, often assuming the charge nurse was certified without confirmation. The Director of Nursing and the Administrator both confirmed that the facility lacked a policy on staff CPR certification and did not maintain a list or record of which staff had current CPR certification. The physician interviewed expected the facility to have such a policy and for at least all nursing staff to be CPR certified. The deficiency had the potential to affect all residents who were full code, as there was no assurance that staff present during an emergency would be able to provide CPR.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when an incident occurred involving two residents. One resident, who has severe cognitive impairment and a history of dementia, PTSD, and anxiety disorder, was observed striking another resident in the face. This resulted in a bruise and two facial skin tears for the second resident, who also has severe cognitive impairment and is on hospice care for senile dementia. The incident was witnessed by a Certified Nursing Assistant (CNA) who intervened to separate the residents. The facility's investigation revealed that the altercation began as a verbal dispute between the two residents, which escalated into physical violence. The CNA immediately intervened, and a Registered Nurse (RN) assessed both residents. The resident who was struck had minor injuries, including red areas and small skin tears on the cheek, which were treated with first aid. The resident who initiated the altercation admitted to hitting the other resident because of a verbal insult. The facility's undated Abuse and Neglect policy outlines the prevention and protection of residents from abuse, but the incident indicates a failure in monitoring and intervention. Both residents involved have a history of cognitive impairments and behavioral issues, which were documented in their care plans. Despite these documented risks, the altercation occurred, suggesting a lapse in the facility's ability to effectively monitor and manage residents with known aggressive behaviors.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a resident with a history of inappropriate sexual behavior was found in another resident's room. The incident occurred when a staff member observed the resident sitting on another resident's bed with their pants and underwear pulled down and their hand inside the other resident's brief. The resident being touched was asleep at the time of the incident. The resident who committed the inappropriate act had a history of sexual behaviors and was on medication to manage these behaviors. They also had a diagnosis of dementia with agitation, which contributed to their impaired cognitive skills. The resident had been known to wander into other residents' rooms and had been identified as an elopement risk. Despite these known behaviors, the resident was able to enter another resident's room and engage in inappropriate conduct. The resident who was touched had severe cognitive impairment and was also identified as a wandering risk. At the time of the incident, they were asleep and did not appear to be in distress when assessed afterward. The facility's failure to adequately monitor and prevent the resident with a history of inappropriate sexual behavior from accessing other residents' rooms led to this deficiency.
Lack of Backflow Preventers on Shower Hoses
Penalty
Summary
The facility staff failed to ensure that all shower hoses were equipped with a backflow preventer, a device that prevents toxins from contaminating the facility's potable water supply. This deficiency was observed during a survey on June 26, 2024, affecting all five shower hoses in the facility. Specifically, two shower hoses in the 400 hall shower room, two in the 500 hall shower room, and one in a resident's room were found without backflow preventers. The facility census at the time was 47 residents. During an interview on the same day, the Maintenance Supervisor admitted to not being aware that all shower hoses required backflow preventers, indicating a lack of knowledge or oversight regarding this safety measure. This oversight had the potential to affect all residents in the facility.
Failure to Provide SNF Advance Beneficiary Notice
Penalty
Summary
The facility failed to issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to residents, which is necessary for informing them about potential financial responsibility for services not covered by Medicare. This deficiency affected three residents who continued to stay in the facility after their Medicare Part A benefits ended, without being provided the SNF ABN. The residents had received a Notice of Medicare Non-Coverage (NOMNC) indicating the end of their Medicare Part A benefits, but the SNF ABN was missing from their records. Interviews with the Business Office Manager and the Administrator revealed a lack of awareness regarding the requirement to provide the SNF ABN. The Business Office Manager, responsible for issuing beneficiary notices, was not aware of the need to provide the SNF ABN, and the Administrator was also unaware of this requirement. This oversight led to the failure to inform residents of their potential financial liability for continued services not covered by Medicare.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of unclean and damaged areas within the facility. Specific deficiencies included cobwebs and scuffs on walls, missing privacy curtain hooks, dusty and broken window curtain rods, and broken window blinds in several rooms. Additionally, some rooms lacked privacy curtains, and there were issues with light fixtures, such as missing globes and light bulbs. The utility hall window seal was rusted and dirty, and the air conditioning vent in the Special Care Unit (SCU) had a black mold-like substance. Further observations revealed that the SCU dining room blinds were coated with dust, and there were multiple flies in the dining area, which were landing on residents, tables, and furniture. During an interview, the Administrator stated that maintenance was responsible for cleaning the SCU vents, while housekeeping staff were responsible for monitoring privacy curtains and daily cleaning tasks, including dusting. The facility did not provide a policy on cleaning, and the provided cleaning checklists were undated.
Failure to Conduct Required Background Checks for New Hires
Penalty
Summary
The facility staff failed to conduct necessary background checks for new hires, specifically neglecting to verify the Certified Nurses' Assistant (CNA) Registry and the Family Care Safety Registry (FCSR) for six sampled staff members. This oversight is contrary to the facility's policy, which mandates that all new employees undergo a criminal background check and be screened through the CNA Registry and FCSR before starting employment. The deficiency affected all six sampled staff members, with the facility having a census of 47 residents. During interviews, the Business Office Manager, who had only been working at the facility for a few months, admitted to not having all employee records available due to a recent county takeover. She acknowledged the lack of knowledge regarding the necessary agencies for background checks and was in the process of adding the facility to the FCSR for future background checks. The Administrator confirmed that all new employees should have completed and documented background checks, highlighting a systemic failure in the facility's hiring process.
Failure to Provide Timely Incontinent Care and Repositioning
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the staff did not provide perineal care and repositioning at least every two hours for two residents. Resident #25, who had moderate cognitive impairment and was always incontinent of bowel and bladder, was observed to have not received incontinent care or repositioning from 8:30 A.M. until 11:47 A.M., when CNAs A and B finally provided care. The resident's brief was found saturated with urine and feces, indicating a lack of timely care. Similarly, Resident #29, who had severe cognitive impairment and was also always incontinent, did not receive the required care. The resident was observed sitting in a Broda chair from 8:30 A.M. until being taken to the dining room at 11:53 A.M. without having been repositioned or provided with incontinent care. Interviews with CNAs A and B confirmed that they did not provide the necessary care every two hours as required by the facility's policy. Interviews with the LPN, DON, and Administrator revealed that they expected dependent residents to be repositioned and given perineal care at least every two hours. However, the observations and interviews with the CNAs indicated that this standard was not met, leading to the deficiency in care for the residents involved.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the individual interests and well-being of three residents. Resident #7, who has significant cognitive loss and is dependent on staff for activities of daily living, was observed sitting passively in various locations without engagement in activities that matched his/her preferences, such as cooking, sewing, or being outside. Despite having a care plan that emphasized the need for structured activities and one-on-one engagement, the resident was often left without appropriate stimulation or interaction. Resident #12, who also has significant cognitive loss and enjoys arts, crafts, and group activities, was similarly observed without meaningful engagement. The resident expressed a desire for more activities beyond bingo and was often found sitting idly or walking the halls out of boredom. The care plan indicated a need for encouragement and escort to activities, but observations showed a lack of fulfillment of these needs, leading to the resident's dissatisfaction and lack of engagement. Resident #43, with severely impaired cognition, was observed lying in bed with the television on but without sound, and no staff interaction was noted during the observation periods. The resident's care plan highlighted a preference for favorite activities and music, yet these preferences were not met. The Activity Director, new to the role and without prior long-term care experience, struggled to provide adequate activities, particularly for residents with dementia, due to a lack of training and support, contributing to the deficiency in meeting residents' activity needs.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to provide a safe environment by not ensuring that call lights were accessible to residents, affecting two of the twelve sampled residents. Resident #25, who has moderate cognitive impairment, Parkinson's Disease, depression, and asthma, was observed multiple times with the call light out of reach, either on the floor or hanging on the privacy curtain. The resident is dependent on staff for activities of daily living (ADLs) and transfers, and is always incontinent of bowel and bladder. The care plan for Resident #25 emphasized the need for assistance with repositioning and incontinence care, yet the call light was consistently inaccessible. Similarly, Resident #29, who has severe cognitive impairment, traumatic brain injury, dementia, and high blood pressure, was also found with the call light out of reach on several occasions. This resident is totally dependent on staff for ADLs, transfers, and toileting, and has a history of falls. Observations showed the call light either under a pile of clothes and blankets or hanging on the privacy curtain, out of reach. Interviews with staff, including CNAs and an LPN, revealed an expectation that call lights should be within reach at all times, yet this was not consistently practiced, leading to the deficiency.
Failure to Address Weight Loss and Provide Snacks in SCU
Penalty
Summary
The facility failed to recognize and address significant weight loss in three residents, as well as failed to provide adequate snacks and fluids to residents in the Special Care Unit (SCU). Resident #7 experienced a significant weight loss of 17.6 pounds over 180 days, with poor meal intake averaging less than 50%. Despite being on a mechanical texture diet with supplements like Ensure and Med Pass 2.0, the resident was observed multiple times without snacks or drinks, and their water pitcher was empty. The care plan indicated a potential for weight loss, but no new dietary recommendations were made despite the significant weight loss. Resident #44, who had severe cognitive deficits and was on hospice services, also experienced weight loss, losing 11.07% of their body weight over 180 days. The care plan included monitoring for weight loss and encouraging oral intake, but observations showed the resident walking around without access to snacks or drinks, and their water pitcher was empty. There were no dietary notes in the Electronic Medical Record from January to June 2024, indicating a lack of monitoring and intervention for the resident's nutritional needs. Resident #12, with significant cognitive loss, complained of hunger but was not provided with snacks or drinks by the staff. Observations showed the resident without access to snacks or drinks, and their water pitcher was empty. The staff, including CNA C, acknowledged the lack of snack and drink offerings and were unsure why the pitchers were empty. Additionally, Resident #10 experienced a weight loss of 11.7 pounds in less than 30 days, but the facility staff did not identify or report this weight loss to the physician. The Director of Nursing and the Administrator acknowledged the lack of a specific person responsible for entering weight data into the EMR, contributing to the oversight.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, as observed through multiple deficiencies in the management of oxygen equipment. Resident #11, who had a terminal prognosis related to chronic respiratory failure, was found with undated oxygen tubing, an empty humidified water bottle dated over a month prior, and a concentrator filter caked in dust. Despite having a physician's order for oxygen management, these issues persisted over several days, with the resident expressing discomfort and a sore nose due to the inadequate oxygen setup. Resident #27, with moderate cognitive impairment and a diagnosis of COPD, also experienced similar deficiencies. The oxygen tubing was outdated, the humidified water bottle was empty and undated, and the concentrator filter was dusty. Observations over consecutive days showed no improvement, and the resident was found with the nasal cannula improperly placed on one occasion. The care plan did not address the use of oxygen, and the physician's orders lacked specific instructions for equipment maintenance. Resident #151, admitted with lung cancer and anxiety disorder, was observed with a dusty oxygen concentrator and undated tubing. Interviews with staff, including CNAs and an LPN, revealed a lack of awareness and adherence to the facility's oxygen policy, which required weekly maintenance of the equipment. The Director of Nursing and the Administrator acknowledged the expectations for staff to maintain the equipment but noted the absence of a checklist to ensure compliance.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for each resident, as required by their policies and procedures. This deficiency was identified through observation, interviews, and record reviews, affecting two residents out of a sample of twelve, with the potential to impact all residents in the facility. The facility did not provide a policy on Medication Regimen Review, which is crucial for monitoring unnecessary medications, psychoactive medication parameters, and drug irregularities. Resident #12, who has significant cognitive loss, dementia, PTSD, depression, and other conditions, had multiple medications prescribed, including Depakote, Lexapro, Rivastigmine Tartrate, and Trazadone. However, there was no record of a medication regimen review for 2024. Similarly, Resident #44, with severe cognitive deficits and diagnoses including anxiety and Alzheimer's Disease, was prescribed Ativan, Lorazepam Intensol, and Seroquel, but also lacked a medication regimen review for 2024. The facility's administrator acknowledged the issue and mentioned that a new consultant pharmacist had started in June, but no corrective actions were detailed in the report.
Dietary Manager Lacks Required Competencies
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to perform the functions of the food and nutrition services. This deficiency was identified through interviews and record reviews, revealing that the DM did not hold any dietary certification and was not enrolled in any relevant training or classes. The facility did not provide a policy outlining the qualifications required for the DM position. The Administrator acknowledged awareness of the DM's lack of certifications and expressed the expectation that the DM should have the necessary certifications and training. The facility census at the time was 47 residents.
Inadequate Preparation of Pureed Foods
Penalty
Summary
The facility failed to provide food in a form designed to meet individual needs, specifically in the preparation of pureed foods. During an observation of a lunch meal, it was noted that the pureed tuna casserole had a thick, sticky consistency with rice-sized particles, requiring chewing before swallowing. The mashed potatoes also had a thick, sticky consistency, although they were smooth without chunks. The facility did not have a policy regarding the preparation of pureed food, and the Dietary Manager did not measure ingredients when preparing pureed meals, leading to inconsistencies in texture. Further observations revealed that the pureed tortellini contained particles, indicating it was not smooth. Interviews with the Dietary Manager, Administrator, and Registered Dietician confirmed that pureed food should be smooth with no large particles, and recipes should be followed to ensure proper consistency. However, the Dietary Manager relied on visual and taste assessments rather than following specific recipes, contributing to the deficiency in providing appropriately textured pureed foods.
Facility Fails to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to maintain a sanitary environment in its kitchen and food storage areas, which had the potential to affect all residents receiving food from the facility's kitchen. Observations revealed multiple instances of unsanitary conditions, including a dirty microwave in the dining room, trash cans without lids in the dishwashing area, and incomplete chemical testing logs for the dishwasher and sanitizer levels. Additionally, refrigerator and freezer temperature logs were incomplete, and various food items were found unlabeled, undated, and improperly stored. In the dry storage area, a large container of soy sauce was dirty, a bin of white flour was unlabeled and undated, and a container of drink lids was dirty. The walk-in refrigerator contained unlabeled and undated food items, such as thickened juice, shredded lettuce, and pieces of cake. The freezer had ice build-up, and food items like pancakes and ice cream were not labeled or dated. Similar unsanitary conditions were observed in the utility room refrigerators, with dirty shelves and food particles present. Interviews with staff, including a Dietary Aide, the Dietary Manager, the Administrator, and a Registered Dietician, revealed inconsistencies in the documentation and monitoring of food safety practices. Staff were unclear about responsibilities for cleaning and labeling food, and there were discrepancies in the expected frequency of temperature checks and documentation. The facility's policies on food storage and sanitation were not being followed, leading to the observed deficiencies.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking a comprehensive antibiotic stewardship program. The program was supposed to include protocols for optimizing infection treatment, reducing adverse events from inappropriate antibiotic use, and implementing a system to monitor antibiotic use. However, the facility did not provide documentation of these protocols or procedures. Additionally, there was no evidence of designated staff accountable for overseeing antibiotic stewardship, nor was there access to pharmacists or other experts in antibiotic stewardship. The facility also lacked regular reporting on antibiotic use and resistance, and there was no education provided to staff and residents about antibiotic stewardship. During interviews, both the Infection Preventionist and the Director of Nursing, who were new to the facility, were unable to provide data on current antibiotic use or trends of infections within the building. The Infection Preventionist, on their third day, could not determine who was on antibiotics or identify recent infection trends. Similarly, the Director of Nursing was unsure about the current antibiotic use and the monitoring and tracking of antibiotic activity. This lack of knowledge and documentation indicates a significant gap in the facility's infection control practices.
Lack of Dementia Training Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure that staff participated in a dementia and behavior training program before providing direct care to residents in the special care unit. This deficiency affected three of the twelve sampled residents, who exhibited various cognitive and behavioral issues. The facility was unable to provide education records for current employees, indicating a lack of proper training in dementia care and abuse prevention. Resident #9, who had severe vascular dementia with behavioral disturbances, was observed in distress multiple times. The resident was seen yelling out for help and expressing discomfort, but the Certified Medication Technician (CMT) A responded inappropriately by teasing and joking with the resident, which was not acceptable. The resident's comprehensive care plan indicated a need for staff to anticipate needs and reduce distractions, but these measures were not effectively implemented. Resident #44, who had severe cognitive deficits and was at risk for wandering, was observed walking repetitively without access to snacks or drinks. The staff did not offer any refreshments, and the resident's water pitcher was found empty. Additionally, a Certified Nurse Aide (CNA) admitted to not being aware of the resident's PTSD diagnosis and had not received recent dementia education. The facility's administrator acknowledged the lack of staff education on dementia care and recognized the situation with Resident #9 as unacceptable.
Failure to Schedule Tests and Appointments, and Monitor Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality care for three residents. Resident #10, who was diagnosed with Parkinson's Disease, orthostatic hypotension, shoulder pain, muscle wasting, and depression, did not receive a physician-ordered MRI for shoulder pain. Despite the resident experiencing severe pain, reaching a level 10 on a scale of one to ten, the MRI was not scheduled, and no results were found in the medical records. This oversight prevented the resident from being referred to pain management as planned. Resident #12, with moderate cognitive loss and diagnoses including dementia, PTSD, depression, rheumatoid arthritis, insomnia, and GERD, had an incident of blood in the ear. The primary care physician prescribed an antibiotic and ordered a consultation with an ENT specialist. However, the facility failed to schedule the ENT appointment, and there was no record of the consultation being completed. This lack of follow-through on the physician's order left the resident without the necessary specialist evaluation. Resident #44, who had severe cognitive loss and diagnoses of anxiety, dementia, Alzheimer's Disease, and cognitive communication deficit, was prescribed Lorazepam Intensol Oral Concentrate for restlessness and anxiety. The medication order did not include a stop date, which is required for as-needed medications to be reevaluated after 14 days. This omission in the medication order process resulted in the resident potentially receiving medication without proper reassessment.
Facility's Administrative Failures and Vendor Payment Issues Cause Resident Anxiety
Penalty
Summary
The facility failed to effectively utilize its resources to provide essential services for residents, as evidenced by the non-payment of essential service vendors, including staffing agencies. This resulted in the suspension of services from the staffing agency due to overdue invoices, which the facility's administrator was aware of but mistakenly believed had been resolved. The lack of payment and communication with the staffing agency led to a halt in staffing support, impacting the care provided to residents. Additionally, the facility did not ensure continuity of administration or active involvement of the administrator during an impending transition of ownership. This lack of leadership and communication caused significant stress and anxiety among residents and their families. Many residents and family members reported not knowing who the current administrator was or who to contact with concerns, leading to feelings of anger, anxiety, and frustration. The absence of clear communication regarding the transition of ownership further exacerbated these feelings, as residents and families were left to rely on rumors and hearsay about potential changes and the possibility of having to move to another facility. The report highlights the experiences of several residents and their families, who expressed concerns about the lack of information and transparency from the facility. Residents with cognitive impairments, such as dementia, were particularly vulnerable to the stress caused by the uncertainty of the situation. Family members expressed worry about the continuity of care and the potential negative impact on their loved ones' health and well-being. The administrator's limited presence and lack of communication with residents and families contributed to the overall deficiency in the facility's administration and management during this critical period.
Lack of Communication During Ownership Transition Causes Resident Anxiety
Penalty
Summary
The facility failed to ensure that residents and their families were treated with dignity and respect during a transition to a new operator, leading to stress and anxiety among the residents and their families. This deficiency affected nine out of eleven sampled residents. The facility did not communicate effectively with the residents or their families about the transition, leaving them to rely on rumors and hearsay for information. This lack of communication caused significant distress, as residents were uncertain about their future care and living arrangements. Several residents and their family members expressed their concerns and frustrations during interviews. For instance, one resident was upset because they had only heard rumors about the facility's management change and feared they might have to move if the new operator was not ready. Another resident's family member was angry about the lack of communication and worried about the potential impact on their family member's health and well-being. The absence of clear information from the facility led to feelings of disrespect and disregard for the residents' and families' rights and needs. The facility's administrator acknowledged the expectation that both current and new leadership should be available to address questions and concerns from residents and families. However, the administrator did not believe that the transition had caused any stress or anxiety, despite the numerous accounts from residents and their families indicating otherwise. This disconnect between the administration's perception and the residents' experiences highlights the deficiency in communication and respect for resident rights during the transition period.
Failure to Offer Pharmacy Choice to Residents
Penalty
Summary
The facility failed to ensure that residents and their families were offered a choice of pharmacy when the primary pharmacy for the facility changed. This deficiency affected nine out of eleven sampled residents. The facility's policy on promoting and maintaining resident self-determination emphasizes the importance of supporting resident choice, including the choice of healthcare providers. However, the facility did not adhere to this policy when it changed the primary pharmacy to Pharmacy B without notifying the residents or their families or offering them a choice. Several residents and their family members reported that they were unaware of the change in the primary pharmacy. For instance, Resident #1's family member believed that Pharmacy A was the chosen pharmacy at the time of admission and was upset to learn that Pharmacy B was providing medications without their knowledge. Similarly, Resident #2's family member was not offered a choice of pharmacy at admission or when the change occurred. This pattern was consistent across other residents, including those with cognitive impairments, who were not informed or given a choice regarding the change in pharmacy. Interviews with facility staff revealed a lack of communication and responsibility regarding the change in pharmacy. The Social Services Designee and the Administrator both stated that residents and families should be offered a choice of pharmacy at admission and during their stay. However, the Social Services Designee was unaware that all residents' primary pharmacy had been changed to Pharmacy B, and the former Assistant Director of Nursing, who facilitated the change, was no longer employed at the facility. This lack of communication and oversight contributed to the deficiency in honoring resident choice and self-determination.
Failure to Notify and Include Residents and Families in Council Meetings
Penalty
Summary
The facility failed to ensure that residents and families were reasonably notified of Resident Council Meetings and did not honor the residents' requests regarding staff and family attendance at these meetings. This deficiency affected five of the eleven sampled residents. The facility's policy stated that Resident Council Meetings should be noted on the Activities calendar and that reasonable steps should be taken to inform residents and family members of upcoming meetings. However, the facility did not adhere to this policy, as evidenced by the lack of timely notification and the exclusion of family members and staff from a critical meeting about the transition of facility ownership. Resident #4, who is the Resident Council President, was informed of a meeting regarding the transition of ownership only 30 minutes before it was scheduled to occur. This left the resident feeling rushed and anxious, with insufficient time to prepare or notify other residents. The President of the company conducting the meeting did not allow staff to attend, except for one resident representative, and did not permit family members to be contacted or attend due to time constraints. Additionally, a previously scheduled meeting to discuss the transition was canceled by the new operating entity's representative, further contributing to the lack of communication and preparation. Other residents and their family members expressed concerns about the lack of notification and the inability to attend the meeting. Resident #1 and their family member were not informed in time to attend, and Resident #2's family member, who visits daily, was unaware of the meeting. Resident #3, who has dementia, attended the meeting but did not understand the information, causing distress. Resident #11 was also unaware of the meeting until it was over. The facility administrator acknowledged the expectation for leadership to be available for questions and for residents to receive advance notice of meetings, but was unaware of the meeting on 5/2/24.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to provide personal funds and a final accounting to six residents within 90 days of their discharge. This deficiency was identified through interviews and record reviews. The facility did not have a policy in place regarding the refunding of resident funds, which contributed to the issue. The facility census at the time was 47 residents.
Deficient Call System in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a functional call system in each resident's bathroom and bathing area. This deficiency was identified through observation and interview, revealing that the call system was not adequately equipped to allow residents to communicate with staff. The system did not relay calls directly to a staff member or a centralized staff work area, nor did it alert staff in the corridor. The facility had a census of 47 residents at the time of the survey.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to provide personal funds and final accounting to six residents within 90 days upon their discharge. The residents affected had varying balances in the facility's operating account, ranging from $399.00 to $3,321.10. During an interview, the Director of Operations acknowledged the requirement to refund personal funds within 30 days of discharge and stated that these refunds are processed through the corporate accounting department. However, the refunds had been requested but not processed, and the facility did not provide a policy regarding the refunding of resident funds.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to provide drinks, including ice and fresh water, consistent with the residents' needs and preferences, affecting four residents out of a sample of eight. Resident #2, who had moderate cognitive impairment and was dependent on staff for hydration, reported that staff did not bring water as often as desired, and the water glass on the table had been there since the previous day. Observations showed the resident had sunken eyes and cracked lips, indicating possible dehydration. Resident #4, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed with a water pitcher that was full but warm to the touch, with no ice. The resident did not respond to engagement, and the water pitcher remained unchanged throughout the day. Resident #6, also severely cognitively impaired, had dry, cracked lips with a sore, suggesting inadequate hydration. Resident #7, with moderate cognitive impairment, reported not receiving water that day, and the water on the table was lukewarm. Interviews with staff revealed inconsistencies in the provision of water. CNA A mentioned that ice water was usually passed around 9:00 A.M. to 10:00 A.M. but had not been done that day. The Administrator and Director of Nursing stated that water should be passed before, between, and after meals, and residents should be offered hydration frequently throughout the day. However, these practices were not consistently followed, leading to the deficiency in resident hydration.
Deficient Call System Functionality
Penalty
Summary
The facility failed to maintain a functioning call system that allowed residents to effectively communicate with staff. Observations revealed that call lights in multiple rooms on both the secure and open units were activated, but the indicator lights above the doors and on the call light board in the hall did not turn on. Although notifications appeared on the screen at the central nurses' station for the open unit, the secure unit lacked this functionality, leading to a reliance on staff presence at the nurses' station to manually inform others of activated call lights. Interviews with staff, including an LPN and a CNA, confirmed that the call light system had not been working properly for several months, with the lights above the doors previously functioning but now inoperative. The LPN mentioned that the system was incompatible with the building's electrical system, and the CNA noted that if no one was at the nurses' station, staff would be unaware of activated call lights. The Director of Operations was unaware of the malfunctioning indicator lights and expected the system to be fully operational.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility staff failed to report injuries of unknown origin for a resident in a timely manner to the Department of Health and Senior Services (DHSS). On 3/23/24, a resident was found with multiple injuries, including bruising to the right eye, elbows, and right hand, as well as a skin tear on the right wrist. Despite the discovery of these injuries by various staff members, including a Licensed Practical Nurse (LPN), a Certified Nurse Aide (CNA), and a Certified Medication Technician (CMT), the injuries were not reported to the Director of Nursing (DON) or the Administrator immediately. The LPN documented the injuries in the medical record but failed to notify the appropriate authorities. The Director of Nursing became aware of the injuries on 3/25/24 through the nurse's notes, and the Administrator acknowledged that the report to the state agency was delayed beyond the required two-hour window. The resident involved had severe cognitive impairment, was dependent on a walker, and required assistance with daily living activities. The facility's policy mandates prompt reporting and investigation of such incidents, but this protocol was not followed, resulting in a deficiency in reporting suspected abuse, neglect, or injuries of unknown origin.
Incomplete Investigation of Resident's Injuries
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for a resident who was found with bruising on the arms, right eye, and a skin tear on the right arm. The facility did not follow its policy, which required interviewing all staff who had contact with the resident and providing complete documentation of the investigation. The investigation lacked statements from key staff members who were present during the time of the incident, and there was no documentation of interviews with the resident's family or other potential witnesses. The resident involved had severe cognitive impairment, was dependent on a walker for mobility, and required assistance with daily living activities. The resident had a history of wandering and was at risk for falls due to impulsiveness and decreased safety awareness. On the morning of the incident, staff discovered the resident with bruises and a skin tear, but there was no record of a fall or any incident that could explain the injuries. The facility's investigation was incomplete, as it did not include statements from all relevant staff or a thorough review of the events leading up to the injuries. Interviews with staff revealed inconsistencies and gaps in the investigation process. The Director of Nursing (DON) and Administrator were involved in the investigation but did not use formal documentation forms, and some interviews were not recorded. The DON was unaware of the incident until two days later, and the investigation lacked a written summary. The facility's failure to conduct a comprehensive investigation and document findings properly resulted in a deficiency in addressing the resident's injuries of unknown origin.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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