Apple Ridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waverly, Missouri.
- Location
- 100 West Thomas Avenue, Waverly, Missouri 64096
- CMS Provider Number
- 265420
- Inspections on file
- 16
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Apple Ridge Care Center during CMS and state inspections, most recent first.
Two residents with behavioral health diagnoses were left unsupervised on a locked unit when a CMT left to retrieve medication records during an internet outage. In the absence of staff, a verbal and physical altercation occurred between the residents over delayed medication administration. Staff interviews confirmed that the unit was left unattended, and facility leadership acknowledged that supervision should have been maintained at all times.
Two residents with psychiatric diagnoses engaged in a verbal and physical altercation when the behavioral health locked unit was left unsupervised by staff. The incident escalated after one resident became upset about delayed medication administration due to an internet outage, leading to yelling and one resident striking the other. Multiple interviews confirmed that no staff were present on the unit at the time, and the facility's policy requiring active protection from abuse was not followed.
Residents without personal phones were required to use the nurses' office phone, where staff presence and the phone's location prevented private conversations. Several residents with mental health and developmental diagnoses reported being unable to make private calls, and staff confirmed that privacy was only offered if specifically requested, with supervision maintained by keeping the office door ajar. The facility had previously provided a portable phone for private use, but this was discontinued, leaving no alternative for residents needing privacy.
A facility failed to protect resident confidentiality when a maintenance director, unaware of HIPAA regulations, disposed of 136 residents' medical records in a public dumpster. The records, labeled with names and years, were accessible until discovered. Other staff, including an LPN and a housekeeper, were aware of proper PHI disposal procedures, but these were not followed in this incident.
The facility failed to maintain a comprehensive infection prevention and control program, particularly for Legionella and TB testing. The Legionella Water Management Plan was incomplete, and several residents did not receive the required two-step TB skin test upon admission. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds or indwelling medical devices, with staff lacking awareness and training on EBP requirements.
The facility failed to provide a comprehensive activities program for residents, affecting their physical, mental, and psychosocial well-being. A resident expressed dissatisfaction with the lack of weekend activities, while another noted that behavior issues among some residents limited their participation. Observations confirmed the absence of activities, and staff interviews revealed that activities were not conducted regularly, especially on weekends, due to the Activities Director's absence.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's specific needs and triggers. Despite having a care plan, staff lacked recent training on PTSD, contributing to inadequate care. The facility's policy required training, but documentation of recent sessions was unavailable.
A facility failed to accurately document narcotic pain medication for several residents, leading to discrepancies between the Medication Administration Record (MAR) and narcotic count logs. Interviews revealed that narcotic counts were not consistently conducted at shift changes, and there were missing signatures on count sheets. Staff admitted to not always counting liquid narcotics, assuming they were full and unopened. The Director of Nursing acknowledged responsibility for ensuring accurate narcotic counts and documentation.
The facility failed to document and provide education on pneumonia vaccinations for five residents upon admission, as required by their policy. Interviews with staff revealed uncertainty about who was responsible for ensuring this education, contributing to the deficiency.
The facility failed to provide and document COVID-19 vaccine education for five residents and five staff members. Interviews revealed confusion among staff about responsibility for vaccine education, with the ADON assuming the DON was responsible and the Regional Nurse believing it was unnecessary post-Public Health Emergency. The DON was unsure if education was provided, indicating a systemic issue in managing COVID-19 vaccination protocols.
A facility failed to provide written notification of a hospital transfer to a resident and the Ombudsman. The resident, who had moderate cognitive impairment, was sent to the hospital after a fall. Interviews revealed that the resident was unaware of any written notification, and the DON confirmed that notifications should have been issued to both the resident and the Ombudsman.
A facility failed to provide a written bed hold policy notification to a resident with moderate cognitive impairment who was transferred to the hospital after a fall. The resident was unaware of receiving such notification, and the LPN confirmed the requirement for written provision. The DON acknowledged the oversight.
A facility failed to complete an annual MDS for a resident, as required by federal guidelines. The MDS Coordinator, who took over after the due date, noted that the previous program lacked notifications for overdue assessments. The facility switched to a new system that provided due dates, but this change occurred after the MDS was already overdue. The DON confirmed the need for timely MDS completion.
A facility failed to complete MDS assessments for a resident at the required intervals. The resident's third quarterly MDS was completed one month late, and the annual MDS was not completed. The MDS Coordinator noted that the previous software did not provide overdue notifications, contributing to the oversight. The facility switched to a new program, but the resident's MDS was already overdue.
A resident with dysphagia and gastrostomy status was not accurately assessed for dental issues, despite having broken teeth and reporting daily pain. The MDS did not document these concerns, and interviews revealed that the MDS nurse and DON were unaware of the resident's dental condition, indicating a failure in the assessment process.
The facility failed to personalize care plans for two residents, leading to deficiencies in communication and dental care. One resident's communication care plan lacked specific interventions despite their preference for Spanish and moderate cognitive impairment. Staff relied on family for translation and used basic Spanish and gestures. Another resident with dysphagia and broken teeth had no dental care plan, and staff were unaware of their dental issues, despite the resident reporting daily pain. These deficiencies highlight inadequate care planning.
The facility failed to ensure the activities program was directed by a qualified professional. The current Activities Director (AD) lacked the necessary qualifications, including two years of college, relevant experience, or state-approved training. The Administrator acknowledged the deficiency, and an attempt to interview the AD was unsuccessful. The facility's policy for the AD was requested but not provided.
A resident with dysphagia and broken teeth did not receive necessary dental care, despite expressing daily pain. The facility staff, including the SSD, LPN, CNAs, and DON, were unaware of the resident's dental issues, and the resident was not seen by the dentist during the last visit. There was no documentation of a dental consent form being provided upon admission.
The facility did not post complete daily nurse staffing information, omitting total actual hours worked for RNs, LPNs, CMTs, CNAs, and NAs. Observations showed missing data on staffing sheets near the nurse's station and no postings in the Behavioral Unit. Staff interviews confirmed the incomplete postings.
A resident with impaired cognition was injured in a dining room altercation when another resident, known for verbal symptoms, hit them on the head with a ringed hand. The incident was triggered by the victim flipping another resident's hat. No staff witnessed the event, and the injury was discovered by a CNA during a shower. The aggressor admitted to the inappropriate behavior.
Failure to Maintain Supervision on Behavioral Health Unit Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate staffing coverage and supervision on the secure behavioral locked unit, resulting in an altercation between two residents. On the evening in question, a Certified Medication Technician (CMT) left the behavioral unit unsupervised to retrieve printed Medication Administration Records (MARs) due to an internet outage, leaving no staff present on the unit. During this period, two residents engaged in a verbal and physical altercation in the hallway, with one resident striking the other in the upper arm after a dispute over delayed medication administration. The residents involved had significant behavioral health diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. One resident was moderately cognitively impaired, while the other was cognitively intact but had a history of agitation when routines or medication schedules were disrupted. The incident occurred after one resident became upset about not receiving medication on time, leading to a confrontation and subsequent physical contact. Interviews with staff and residents confirmed that the behavioral unit was left without staff supervision at the time of the incident. Multiple staff members, including the CMT, LPNs, CNAs, the Administrator, and the DON, acknowledged that the behavioral unit should never be left unattended and that at least one staff member should always be present. The facility was unable to provide a staffing policy at the time of the survey exit.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to prevent verbal and physical abuse between two residents on the behavioral health locked unit. On the evening of 12/26/25, two residents with significant psychiatric diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression, engaged in a verbal and physical altercation. The incident occurred after one resident became upset about not receiving medication due to a facility internet outage, which delayed the medication pass. The two residents exchanged words, escalated to yelling, and then one resident struck the other in the upper arm. At the time of the incident, there were no staff members present on the locked behavioral unit. The Certified Medication Technician (CMT) assigned to the unit had left to print medication administration records necessary for the medication pass, as the internet was down. Multiple resident interviews confirmed that staff were not present during the altercation, and one resident had to bang on the locked doors to alert staff to the fight. Staff interviews corroborated that the unit was unsupervised during the event, and the administrator acknowledged that staff supervision was expected at all times on the unit. The facility's own Abuse and Neglect Policy states that residents have the right to be free from abuse and that the facility will actively protect residents from such incidents. The lack of staff supervision on the locked behavioral unit directly contributed to the occurrence of resident-to-resident abuse, as there was no immediate intervention or oversight to prevent or de-escalate the situation.
Failure to Provide Private Telephone Access for Residents
Penalty
Summary
The facility failed to ensure that residents on the locked unit had the opportunity to make and receive phone calls without being overheard, as required by their own policy. Residents who did not possess their own phones were required to use the telephone located in the nurses' office, where privacy could not be guaranteed. Staff were typically present in the office during resident calls, and the phone's location and short cord length further limited privacy. Residents reported that staff rarely offered privacy, and even when requested, staff would leave the door ajar to monitor the resident, allowing conversations to be overheard in the hallway. Multiple residents on the locked unit, including individuals with schizoaffective disorder, ADHD, and autistic disorder, expressed dissatisfaction with the lack of privacy during phone calls. These residents indicated that they would prefer to have private conversations but were not provided with a means to do so. The facility previously had a portable phone that allowed residents to make private calls, but this was discontinued about a year prior when a new phone system was installed. Since then, no alternative arrangements for private phone access had been made for residents without personal phones. Staff interviews confirmed that the only phone available for resident use was in the nurses' office and that staff presence was standard unless privacy was specifically requested. Even then, privacy was limited due to the need to keep the door ajar for supervision. There were also informal restrictions on when residents could use the phone, depending on staff availability, and some staff imposed time limits on calls. The facility's administration and nursing leadership acknowledged these practices and the absence of a portable phone, but no clarification or alternative had been provided to ensure residents' right to private communication.
Improper Disposal of Medical Records Breaches Resident Confidentiality
Penalty
Summary
The facility failed to maintain personal privacy and confidentiality of residents' personal and medical records by disposing of protected health information (PHI) in a public dumpster. This incident involved 136 residents, with medical records dating from 2008 to 2018 being placed in closed boxes and discarded off-site at a laundry building. The boxes were labeled with residents' names and years, making the information easily identifiable. The maintenance director was responsible for placing the records in the dumpster, and the administrator was notified of the breach after the records were discovered. Interviews revealed that the maintenance director was not aware of HIPAA regulations at the time of the incident and mistakenly disposed of the records in the dumpster. Other staff members, including an LPN and a housekeeper, demonstrated awareness of HIPAA requirements and stated that protected information should be placed in designated shred boxes or given to a charge nurse for proper disposal. The facility's policies required that PHI be managed and protected to prevent unauthorized release or disclosure, but these procedures were not followed in this instance, resulting in a breach of confidentiality.
Infection Control and EBP Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, specifically for Legionella and other water-borne pathogens. The facility's Legionella Water Management Plan was incomplete and outdated, with numerous sections left blank, including risk assessments, control measures, and documentation of maintenance activities. The facility lacked a Director of Maintenance to implement the program, and the Administrator acknowledged the absence of a responsible person for the Legionella program. The facility also failed to ensure that all residents received a two-step tuberculosis (TB) skin test upon admission. Several residents' medical records lacked documentation of the TB skin test, and there was no guidance in the facility's policy for completing the test. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed inconsistencies in the administration and documentation of the TB skin tests. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds or indwelling medical devices. Observations and interviews indicated that staff were not aware of which residents required EBP, and there were no signs or isolation carts to indicate the need for EBP. Staff interviews revealed a lack of understanding and training on EBP, and the Infection Preventionist was not present to ensure compliance.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and well-being of residents, as evidenced by the lack of activities for three sampled residents. Resident #19, who was cognitively intact, expressed a desire to go outside and engage in activities like playing cards and working with models. However, the resident's participation logs showed limited engagement, primarily in coffee club and bingo, with no activities scheduled on weekends. The resident reported a lack of activities on weekends and mentioned that the Activity Director was unsure of what to plan for the residents. Resident #23, who was moderately cognitively impaired, also experienced a lack of activities, particularly on weekends. The resident's participation logs indicated sporadic involvement in coffee club and bingo, with no logs available for September. The resident expressed dissatisfaction with the lack of activities and noted that due to behavior issues among some residents, they were no longer allowed to participate in activities with others. Similarly, Resident #36, who was cognitively intact and valued listening to music and going outside, reported a lack of activities and an absence of a current activities calendar. Observations from 9/9/24 to 9/11/24 confirmed the absence of activities on the unit. Interviews with staff, including CNAs and a CMT, revealed that activities were not conducted regularly, especially on weekends, and that the Activities Director was out due to illness. The Director of Nursing was unaware of the lack of activities on weekends and who was responsible for conducting them in the absence of the Activities Director. The deficiency in providing a comprehensive activities program had the potential to affect all residents in the facility.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was moderately cognitively impaired, had a care plan that included approaches for managing mental distress related to PTSD. However, observations and interviews revealed that staff were not fully aware of the resident's needs or specific triggers associated with PTSD. The resident exhibited behaviors such as pacing and restlessness, and sometimes expressed feelings of claustrophobia while smoking outside. Interviews with staff, including CNAs and LPNs, indicated a lack of awareness and training regarding the resident's PTSD diagnosis and associated care needs. Some staff were unsure of the resident's specific triggers and had not received recent training on PTSD. The MDS coordinator and the Director of Nursing also expressed a lack of knowledge about the resident's PTSD history and the frequency of trauma-informed care training provided to staff. The facility's Trauma Informed Care Policy outlined the need for staff training and the inclusion of trauma-informed care in the Quality Assurance Improvement Plan. However, the administrator and the Regional Nurse Consultant were unable to provide documentation of recent training sessions, indicating a gap in the implementation of the policy. This lack of training and awareness among staff contributed to the deficiency in providing appropriate trauma-informed care for the resident.
Narcotic Documentation and Count Discrepancies
Penalty
Summary
The facility failed to ensure accurate documentation of narcotic pain medication on the Medication Administration Record (MAR) and the narcotic count log for four residents. This deficiency was identified through interviews and record reviews, revealing discrepancies in the documentation and administration of narcotic medications. For instance, Resident #8's records showed that 102 Oxycodone tablets were documented as administered, but only 51 tablets were accounted for in the narcotic log, indicating a significant discrepancy. Additionally, there were instances where two tablets were signed out simultaneously, contrary to the physician's order for one tablet. Further investigation into Resident #23's records showed that 12 Hydrocodone tablets were unaccounted for, as the narcotic log and MAR did not match. Similarly, Resident #19's records indicated that 53 Norco tablets were documented as administered, but only 47 were signed out, leaving six tablets unaccounted for. Resident #36's records also showed discrepancies, with several Oxycodone tablets unaccounted for across different months. These inconsistencies highlight a failure in the facility's medication management and documentation processes. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that narcotic counts were not consistently conducted at shift changes, and there were numerous instances of missing signatures on narcotic count sheets. Staff admitted to not always counting liquid narcotics stored in the refrigerator, assuming they were full and unopened. The DON acknowledged responsibility for ensuring accurate narcotic counts and documentation but noted that there were many blanks on the narcotic sheets, indicating lapses in the facility's procedures.
Failure to Document and Educate on Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and education regarding pneumonia vaccinations for five residents upon their admission. The facility's policy, dated March 2022, mandates that all residents be offered pneumococcal vaccines and be assessed for eligibility prior to or upon admission. Additionally, residents or their representatives should receive education about the benefits, risks, and potential side effects of the vaccine. However, for Residents #15, #32, #36, #37, and #342, there was no documentation of their pneumonia vaccination status, no record of them being offered the vaccine, and no evidence that they were provided with the necessary educational information upon admission. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring that pneumonia education is provided upon admission. The Assistant Director of Nursing (ADON) was unsure who was responsible for this task, while the Director of Nursing (DON) acknowledged that pneumonia education and vaccination records should be documented in the resident's medical record upon admission. The DON also expressed uncertainty about whether the residents received the required education regarding pneumonia vaccines. This lack of documentation and clarity in roles contributed to the deficiency identified by the surveyors.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure the provision and documentation of education regarding the COVID-19 vaccine for both residents and staff. Specifically, five residents and five staff members were not provided with education about the benefits, risks, and potential side effects of the COVID-19 vaccine upon admission or hire. The facility's policy requires that each resident be offered the vaccine unless contraindicated and that education be provided in an understandable format. However, there was no documentation in the medical records of the sampled residents or the employment records of the sampled staff indicating that this education was provided. Interviews with facility staff revealed a lack of clarity and responsibility regarding the provision of COVID-19 vaccine education. The Assistant Director of Nursing (ADON) stated that they did not provide the education and assumed the Director of Nursing (DON) was responsible. The Regional Nurse expressed the belief that the facility was not required to obtain vaccination status or provide education since the Public Health Emergency had ended. The DON acknowledged that vaccination records should be maintained but was unsure if education was provided to residents and staff. The deficiency highlights a breakdown in the facility's processes for ensuring compliance with its own policies on COVID-19 vaccination education and documentation. The lack of documentation and education for both residents and staff indicates a systemic issue in the facility's approach to managing COVID-19 vaccination protocols. This failure to adhere to established policies could potentially impact the health and safety of both residents and staff.
Failure to Notify Resident and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of a hospital transfer/discharge for one resident, as well as to the Ombudsman, when the resident was transferred to the hospital. The incident involved a resident who was found on the floor and complained of pain in the right hip. The facility's physician was notified, and orders were given to send the resident to the emergency room. However, there was no documentation in the resident's paper chart or electronic health record indicating that a transfer/discharge notification was provided to the resident or the Ombudsman. Interviews conducted during the investigation revealed that the resident was unaware of receiving any written notification regarding the hospital transfer. A Licensed Practical Nurse (LPN) mentioned that the physician and family were typically notified in writing when residents were transported out of the facility, and that the Ombudsman must also be notified. The Director of Nursing (DON) confirmed that transfer/discharge notifications should have been issued to the resident and the Ombudsman, and that family and residents should be notified in writing with the reason for the transfer.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its Bed Hold policy to a resident who was transferred to the hospital. This deficiency was identified for one resident out of a sample of 13, in a facility with a census of 40 residents. The resident, who had moderate cognitive impairment, was sent to the emergency room following a fall and subsequent complaint of hip pain. A review of the resident's nurse progress notes and health records showed no evidence that the bed hold policy was issued. During interviews, the resident expressed unawareness of receiving any written notification regarding bed hold, and the LPN confirmed that bed hold policies must be provided in writing. The DON acknowledged that a bed hold policy should have been issued when residents are sent to the hospital.
Failure to Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) for a resident, as required by federal guidelines. The resident's admission MDS was completed, but the subsequent annual MDS, which was due within 366 days, was not completed. This oversight was identified during a review of the resident's assessments, which showed that the annual MDS was due but not completed. The facility's policy indicated that the assessment coordinator or designee was responsible for ensuring timely submission of assessments according to federal and state guidelines. The MDS Coordinator, who assumed the role after the annual MDS was due, stated that the previous program used for MDS completion did not provide notifications for past due assessments. The facility switched to a new program, which provided a list of residents and their MDS due dates, but this transition occurred after the annual MDS was already overdue. The Director of Nursing confirmed that MDS assessments should be completed timely, following the guidelines in the Resident Assessment Instrument Manual.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for a resident at the required intervals, as mandated by federal guidelines. The resident's admission MDS was completed on January 27, 2023, followed by the first and second quarterly MDS on April 24, 2023, and July 22, 2023, respectively. However, the third quarterly MDS, due on October 22, 2023, was not completed until November 2, 2023, making it one month late. Furthermore, the annual MDS due on January 28, 2024, was not completed, and no assessments were conducted after April 19, 2024. The MDS Coordinator, who assumed the role in February 2024, indicated that the previous software used for MDS completion did not provide notifications for overdue assessments, which contributed to the oversight. The facility transitioned to a new program on August 19, 2024, which provided a list of due assessments, but by then, the resident's MDS was already overdue. The Director of Nursing acknowledged that the MDS should be completed timely, in accordance with the Resident Assessment Instrument (RAI) manual.
Failure to Accurately Assess Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess a resident's oral and dental status, specifically regarding broken natural teeth and mouth pain. The resident, who had been admitted with diagnoses including dysphagia and gastrostomy status, was noted in the Admission Nursing Evaluation to have broken teeth. However, the Minimum Data Set (MDS) completed for the resident did not document any dental concerns, such as broken or missing teeth, or mouth or facial pain. This discrepancy indicates a failure in the assessment process, as the MDS did not reflect the resident's actual condition as observed and reported. Interviews with the MDS nurse and the Director of Nursing (DON) revealed that neither was aware of the resident's broken teeth, despite the resident expressing daily concerns about dental pain. The MDS nurse expected the MDS to accurately reflect the resident's condition based on nursing assessments, yet failed to capture the necessary documentation from the clinical chart. The DON also expected the MDS to be accurate and for the MDS nurse to conduct thorough assessments, highlighting a gap in communication and assessment practices within the facility.
Deficiencies in Communication and Dental Care Plans
Penalty
Summary
The facility failed to personalize a communication care plan for two residents, leading to deficiencies in their care. For the first resident, the admission Minimum Data Set (MDS) indicated that Spanish was their preferred language, and they were moderately cognitively impaired. Despite this, the communication care plan lacked specific interventions and details on how to assist the resident with communication. Observations showed the resident communicated in Spanish and used a translator application, while staff interviews revealed reliance on family members for translation and the use of hand gestures and basic Spanish by some staff. The MDS Coordinator acknowledged the care plan should have included specific communication interventions. The second resident had a history of dysphagia and gastrostomy status, with broken teeth noted in the Admission Nursing Evaluation. However, the MDS did not document any dental concerns, and the care plan lacked a dental care plan. Observations confirmed the resident had multiple missing and broken teeth, and the resident reported daily pain and concerns about their teeth. Interviews with staff, including the LPN, Social Services Designee, CNAs, and the MDS nurse, revealed a lack of awareness of the resident's dental issues. The Director of Nursing also confirmed the expectation that the care plan should reflect dental concerns. These deficiencies highlight the facility's failure to ensure comprehensive and personalized care plans for residents, particularly in addressing communication needs and dental health. The lack of specific interventions and awareness among staff contributed to the inadequate care planning for these residents.
Unqualified Activities Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by their own job description and state regulations. The facility's policy for the Activities Director (AD) was requested but not provided. The job description for the AD position specified that the individual must possess at least two years of college, be a qualified therapeutic recreation specialist, or have relevant experience or training. However, the current AD, who has been in the position for three months, did not meet these qualifications. The AD was a Certified Medication Technician (CMT) and a Certified Nurse Assistant (CNA) with a General Education Development (GED) and one year of college, but lacked the necessary experience or state-approved training. During an interview, the Administrator acknowledged that the AD did not have the required qualifications and needed to become qualified. An attempt to interview the AD was made, but the call was not returned. The facility census at the time was 40 residents, indicating that the deficiency could potentially impact a significant number of individuals. The lack of a qualified professional to direct the activities program represents a failure to comply with regulatory standards and the facility's own policies.
Failure to Provide Dental Care for Resident with Broken Teeth
Penalty
Summary
The facility failed to provide routine and emergency dental services to a resident, identified as Resident #37, who had multiple missing and broken teeth. The resident, who was admitted with a diagnosis of dysphagia, expressed daily pain and concern regarding their dental condition. Despite having an order for a dental consult and treatment, the resident was not seen by the dentist during the last visit on 7/25/24, and there was no documentation of a dental consent form being provided upon admission. Interviews with facility staff, including the Social Service Director (SSD), Licensed Practical Nurse (LPN), Certified Nurses Aides (CNAs), and the Director of Nursing (DON), revealed a lack of awareness regarding the resident's dental issues. The SSD was responsible for obtaining dental consents and scheduling appointments but was unaware of the resident's broken teeth and the last provision of dental services. The CNAs and MDS nurse also did not recognize the resident's dental needs, and the resident had not reported the need for dental care to them.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted correctly at the beginning of each shift, as required by federal regulations. The posted staffing sheets from 9/5/24 through 9/11/24 did not include the total actual hours worked for each discipline, such as RNs, LPNs, CMTs, CNAs, and NAs. Observations on multiple dates confirmed that the staffing sheets near the front nurse's station lacked this information, and no staffing sheets were posted in the locked Behavioral Unit. Interviews with staff, including a CNA, an LPN, and the Director of Nursing, revealed that the daily staffing sheet was only posted near the main nursing station and not in the Behavioral Unit. The Director of Nursing acknowledged that the form used by the facility did not show a total for the actual hours worked per discipline and confirmed that the staffing sheet should also be posted in the locked Behavioral Unit.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents. On the morning of April 3, 2024, in the dining room, one resident hit another on the head, causing an abrasion. The aggressor was wearing a ring, which contributed to the injury. The incident was triggered when the victim flipped the hat of another resident, which agitated the aggressor. The victim of the altercation had a history of severely impaired cognition due to Alzheimer's Disease and other medical conditions, while the aggressor was cognitively intact but had a history of verbal symptoms towards others. The aggressor admitted to hitting the victim and acknowledged that it was inappropriate behavior. There were no staff witnesses to the incident, and it was reported by a CNA who noticed the abrasion during a shower. Interviews with other residents and staff revealed that the victim had a history of behaviors that could provoke others, such as teasing and stealing. The aggressor was known to be easily annoyed and had a tendency to meddle. Despite these known behaviors, the facility did not prevent the altercation, resulting in a failure to protect the resident from abuse.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
