Appleton City Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Appleton City, Missouri.
- Location
- 600 North Ohio, Appleton City, Missouri 64724
- CMS Provider Number
- 265843
- Inspections on file
- 25
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Appleton City Manor during CMS and state inspections, most recent first.
A resident with schizophrenia, bipolar disorder, HTN, and type 2 DM was admitted with conflicting code status documentation: one page of the face sheet and the emergency book listed DNR, while another page of the face sheet, the physician’s orders, and a signed health care directive defaulted the resident to full code (CPR). One morning, a CNA found the resident unresponsive across the bed and summoned an RN, who noted no pulse, no respirations, and cyanosis but did not initiate CPR, relying on the DNR status shown in the emergency materials. Interviews with CNAs, LPNs, the MDS coordinator, SSD, DON, NP, Medical Director, and Administrator confirmed that, in the absence of a signed DNR or when documentation conflicted, the resident should have been treated as full code and CPR started, but this did not occur, leading to the cited deficiency.
A resident with significant mobility and cognitive impairments, who required staff assistance and a mechanical lift for transfers, was injured when a CNA hurriedly attempted to reposition the resident in a Broda chair without proper communication or technique. The CNA, who had not completed documented training or skills competency, pushed on a stuck lever, causing the resident to fall and sustain a mouth laceration and a hairline fracture. Staff and family interviews confirmed the CNA did not follow facility policy for safe repositioning.
A resident in a LTC facility made a threatening statement towards others during a smoke break, but the facility failed to report this potential abuse to the DHSS within the required two-hour timeframe. Staff intervened and documented the incident, but there was confusion about the reporting process, leading to a delay in notifying the appropriate authorities.
A resident with lung cancer and COPD was found with marijuana and unknown pills in their room, which were not documented in their care plan. The facility failed to follow its policies on incidents, smoking, and medication storage, leading to a deficiency. Staff were unaware of the resident's possession of these items, and there was a lack of communication and documentation regarding the incident.
A resident with a history of anxiety, depression, and insomnia exhibited distressing behaviors, including verbal aggression and refusal of care. The facility failed to implement non-pharmacological interventions, relying instead on medication adjustments. Despite policies emphasizing behavior understanding and minimizing psychoactive medication use, the facility did not provide consistent psychological services or behavior management, leading to a deficiency in care.
A resident with a history of depression and anxiety exhibited distressing behaviors, including yelling and refusing care, which were not adequately addressed by the Social Services Designee (SSD). The resident expressed unhappiness with the facility and a desire to move, but the SSD did not follow up or provide necessary interventions. The resident's behaviors were often related to smoking and dissatisfaction with staff response times, particularly during the evening shift. The SSD lacked training and was unaware of her responsibilities in monitoring and addressing residents' behaviors.
The facility failed to implement effective infection control practices, including Enhanced Barrier Precautions (EBP) and proper hand hygiene, during wound care for two residents. Staff did not follow standard practices, such as changing gloves or sanitizing hands between wound measurements, potentially contaminating wounds. Observations showed that staff lacked knowledge about EBP and did not consistently use personal protective equipment (PPE) during care.
A resident with multiple medical conditions and at risk for pressure ulcers did not receive consistent care and documentation for their wounds. The facility failed to perform weekly skin assessments and obtain treatment orders for all wounds. Observations showed multiple open areas on the resident's buttocks without corresponding treatment orders. Staff interviews revealed inconsistencies in wound care practices and communication, leading to inadequate care for the resident's pressure ulcers.
The facility failed to maintain adequate RN coverage and did not have a full-time Director of Nursing (DON) after the previous DON resigned without notice. Interviews and staffing sheets revealed inconsistent RN coverage, with the previous DON working various shifts before leaving. The facility was actively seeking to fill these positions through advertisements and potential contracts.
The facility failed to manage residents' personal funds according to regulations, particularly for those receiving Medicaid services. Funds exceeding $50 were not deposited into an interest-bearing account, and there was inadequate documentation and access to funds for several residents. The Business Office Manager acknowledged the funds were kept in a safe, not in an interest-bearing account, despite knowing the requirement.
A resident with a history of traumatic subdural hemorrhage and monoplegia was transferred without a Hoyer lift, contrary to physician orders and facility policy. The resident's care plan required Hoyer lift transfers due to non-ambulatory status, but a nurse aide manually transferred the resident, believing the order was PRN. Staff interviews confirmed the requirement to use the Hoyer lift, highlighting a deficiency in accident hazard prevention and supervision.
A resident with severe cognitive impairment and a history of intracerebral hemorrhage experienced increased edema and weight gain due to the facility's failure to administer medications as ordered, monitor the resident's condition, and notify the physician in a timely manner. Despite orders to decrease amlodipine and monitor blood pressure, staff inconsistently checked vital signs and failed to document or communicate the resident's worsening condition, leading to significant health issues.
The facility did not ensure RN coverage for at least eight consecutive hours daily, as required. Review of work schedules for several months showed multiple days without an RN scheduled. Interviews with staff revealed uncertainty about RN availability, and the administrator noted staffing limitations, with only two RNs employed, one part-time.
The facility failed to ensure that eight nurse aides completed CNA training within four months of employment, as required by policy. Observations showed aides providing direct care without certification, and interviews revealed repeated delays in certification due to facility issues. The administrator acknowledged the problem, but no corrective actions were mentioned.
The facility failed to ensure the Dietary Manager had the necessary certification or experience for the role. Despite being employed since 2005, the Dietary Manager had no training in food service management. The facility's policy lacked clarity on required qualifications, and the Administrator acknowledged the need for training but had not yet implemented corrective actions.
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, with observations of debris, greasy residues, and improper food handling. The kitchen lacked structured cleaning protocols, and food preparation areas were not sanitized after handling trash. Flies were present, and food storage temperatures were not properly monitored, leading to spoiled and improperly stored food items. The Dietary Manager and Registered Dietician acknowledged these issues, but facility practices did not align with policies.
The facility did not submit the required PBJ Staffing Data Report to CMS for the second quarter of 2024. The new Administrator, who started in July, found that the report had not been completed for some time and was unable to enter data for the previous period. She was unaware of who was responsible for the submission prior to her tenure.
The facility did not maintain an effective QAPI plan, lacking documentation of Performance-Improvement-Plans (PIPs) and evidence of attempts to correct deficient practices. There was no infection preventionist or medical director input in the QAPI process. The Administrator could not find any QAPI policy or procedure, nor provide documentation of PIPs or weekly reviews for identified problems.
The facility failed to maintain documentation of a functioning QAA Committee that met quarterly with required members. The facility lacked a policy for the QAA Committee, and records showed no documentation of quarterly meetings. Additionally, there was no Infection Preventionist, and the medical director did not regularly attend meetings. The Administrator confirmed these issues during an interview.
The facility failed to implement a comprehensive infection control program, lacking processes for Legionella monitoring and proper respiratory hygiene. Staff did not cover clean linens during transport, and wound care supplies were placed on residents' tables without barriers. Enhanced Barrier Precautions were not understood or implemented, with inconsistent PPE use during resident care.
The facility failed to maintain an effective antibiotic stewardship program, lacking a comprehensive log for residents on antibiotics and failing to include antibiotic therapy in care plans for two residents. Staff interviews revealed confusion about responsibility for the program, resulting in inadequate tracking and documentation of antibiotic use.
The facility did not have a designated certified infection preventionist (IP) responsible for the infection prevention and control program. The Administrator was unsure who was monitoring infections, and an LPN confirmed they were not tracking infections. The previous DON and ADON had been responsible, but no current staff member was identified for infection prevention. Another LPN also confirmed they were not monitoring any infection program.
The facility failed to complete Criminal Background Checks (CBC) for four new hires, including Nurse Aides and a Certified Medication Technician, before allowing them to work with residents. Despite policy requirements, the facility did not document the completion of these checks, as revealed through personnel record reviews and staff interviews.
The facility failed to manage code status accurately for residents, leading to discrepancies in documentation and lack of physician orders. A resident's care plan did not reflect their DNR status, while another's care plan incorrectly listed them as DNR. Two residents had conflicting code status information in their records. Staff interviews revealed inconsistencies in the process of documenting and verifying code status.
A facility failed to administer medications as ordered for a resident with severe cognitive impairment and cardiovascular conditions, resulting in a nine-day lapse in medication administration. Additionally, the facility lacked an effective system for timely medication destruction, with numerous medications awaiting disposal. Staff interviews revealed uncertainty about the destruction schedule, and the administrator confirmed that the process was not consistently implemented.
The facility failed to act on pharmacy recommendations for gradual dose reductions of psychoactive medications for a resident and did not complete monthly drug regimen reviews for three residents. Staff interviews revealed confusion about responsibility for these tasks, with the DON, ADON, and LPN providing conflicting information.
A facility failed to provide a bed hold policy for a resident with Alzheimer's and vascular dementia during two hospital transfers. The facility did not document or provide written bed hold information to the resident or their responsible party. Interviews revealed confusion among staff about responsibilities for bed holds, with the LPN unsure of procedures and the Administrator acknowledging lapses in maintaining a bed hold log.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, despite the resident having complex medical conditions. Interviews with staff revealed that care plans should be completed within 24 hours and accessible in the resident's chart, but this was not done, resulting in a deficiency.
The facility failed to provide adequate pressure ulcer care for two residents, with staff not documenting full assessments, updating care plans, or notifying physicians of new or changing wounds. A resident with Alzheimer's and vascular dementia had wounds that were not consistently documented or treated according to orders. Interviews revealed staff's lack of understanding of proper wound care procedures.
A resident with a left-hand contracture did not receive consistent care to maintain or improve ROM due to the facility's failure to ensure the ordered hand splint was consistently used and monitored. The resident's care plan was not updated to include the splint order, and it was not documented in the MAR or TAR. Observations showed the splint was not consistently worn, and staff interviews revealed a lack of clear responsibility and communication regarding its application and monitoring.
The facility failed to provide proper incontinence care for two residents, as staff did not perform hand hygiene or change gloves during care. Observations showed improper cleaning techniques, such as using the same wipe multiple times and not cleansing the genital area. Interviews with staff confirmed that expected procedures were not followed, indicating a lack of adherence to protocols.
A resident with multiple health conditions experienced weight loss, and the facility failed to implement the RD's recommendations for larger meal servings and a dietary supplement. The RD's recommendations were not included in the care plan, and there was no physician order for the supplement. Interviews revealed confusion among staff about responsibilities for implementing dietary changes, leading to a deficiency in maintaining the resident's nutritional status.
A facility failed to obtain physician orders for a resident's CPAP machine, which was used for sleep apnea. The resident's care plan lacked information on CPAP use, and staff were unaware of the necessary care procedures. Interviews revealed that staff had not received training on the machine, and there were no documented orders for its use or settings.
A facility failed to limit PRN psychotropic medications to 14 days for a resident with dementia, who received clonazepam 27 times in a month without an end date. Another resident on quetiapine did not have documented attempts at gradual dose reduction (GDR), despite facility policy requiring such measures. Interviews revealed staff uncertainty about medication review responsibilities and expiration dates for PRN medications.
The facility failed to maintain accurate medical records for two residents, resulting in incomplete documentation of their conditions and hospital transfers. One resident's records lacked a care plan and progress notes for an emergency room visit, while another resident's records did not document the condition leading to a psychiatric unit admission. Staff interviews highlighted the expectation for documenting changes in condition and hospital transfers, but the facility lacked a policy on record accuracy.
The facility did not post the required daily nurse staffing information in a prominent place accessible to residents and visitors. The postings lacked the facility name, total and actual hours worked, and names of key nursing staff. Staff were unaware of posting responsibilities and requirements.
A staff member yelled and used inappropriate language towards another staff member in the presence of a resident with severe cognitive impairments. The incident occurred when the staff member was assisting the resident with a gait belt, despite being advised to use a wheelchair for the resident's safety. Multiple staff members corroborated the incident, noting the behavior was undignified.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not adequately monitoring blood pressure as ordered. The resident had orders for blood pressure medications and monitoring each shift, but staff did not consistently document the readings. Interviews revealed inconsistencies in following orders and a lack of policy for monitoring with medication administration.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not specifying a diagnosis for the use of Ativan for agitation. The resident, with Alzheimer's and dementia, was administered Ativan without a documented diagnosis justifying its use. Staff interviews revealed inconsistent documentation practices, and the facility lacked a policy on psychotropic medications.
The facility failed to ensure residents were treated with dignity and respect when a CNA yelled and used profanity towards another staff member in front of a resident with severe cognitive impairments. Multiple staff members corroborated the incident, noting the CNA's aggressive response when advised to use a wheelchair for the resident's safety.
The facility failed to report allegations of abuse involving a CNA cursing at two residents to the state within the required timeframe. Both residents had significant cognitive impairments and were fully dependent on staff for daily living activities. The incident was reported to the DON six days after it occurred, but the facility did not self-report the abuse to the DHSS.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not adequately monitoring blood pressure as ordered. Despite physician's orders to record blood pressure each shift, staff did not document monitoring on multiple occasions. Interviews revealed inconsistencies in understanding and executing the orders, and the facility lacked a policy and oversight in reviewing MARs and TARS.
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not specifying a diagnosis for the use of Ativan for agitation. The resident, diagnosed with Alzheimer's and dementia, was administered Ativan without a documented diagnosis justifying its use. Staff interviews revealed frequent administration of Ativan without proper documentation, and the facility lacked a policy on psychotropic medications.
Failure to Honor Full Code Status Due to Conflicting Documentation and Omission of CPR
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with a resident’s advance directives and physician orders when staff did not initiate CPR for a resident who was a full code. The resident’s medical record contained conflicting documentation regarding code status: page one of the face sheet listed DNR, while page two listed CPR in the advance directive field. The resident’s current physician’s order sheet contained an order for CPR, and the health care directive form, signed by the resident’s guardian, indicated that the guardian did not wish to make a health care directive at that time, which staff stated defaulted to full code. The Social Services Director and nursing staff reported that, in the absence of a signed DNR, the resident’s status should be full code and CPR should be initiated if the resident was found unresponsive. On the day of the incident, a CNA checked on the resident around 6:00 A.M. and observed the resident sleeping. When the CNA returned around 7:45 A.M. to assist the roommate, the resident was found lying across the bed, appearing as if they had attempted to sit up and then slumped over, and did not respond. The CNA called for the nurse and then checked the emergency book, which indicated the resident was DNR. RN E responded, found the resident lying across the bed with no heartbeat or respirations, lips blue, and a gray appearance, and did not initiate CPR. RN E instead notified the Administrator, and together they pronounced the resident deceased at 7:55 A.M. without starting CPR. Nursing progress notes documented that the resident was found unresponsive at 7:50 A.M., with ashen face and purple lips, and that the resident was pronounced deceased at 7:55 A.M. Multiple staff interviews revealed inconsistent understanding and use of code status information. Staff reported that code status could be found in several locations, including the emergency binder, the electronic medical record, the resident’s door tag (red sticker for DNR), and the face sheet. LPNs, CNAs, the MDS Coordinator, and the SSD stated that if there was no signed DNR or if code status information conflicted, the resident should be treated as full code and CPR should be started and continued until EMS arrived. The DON, SSD, NP, Medical Director, and Administrator all confirmed that the resident’s health care directive and physician orders supported a full code status and that the resident’s code status should have been consistent throughout the record. Despite this, RN E and the Administrator relied on the DNR notation on the face sheet and the emergency book and did not question the discrepancy or initiate CPR when the resident was found unresponsive.
Resident Fall and Injury Due to Improper Repositioning by CNA
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) assisted a resident in a hurried manner, resulting in the resident falling from a wheelchair. The resident, who had diagnoses including contracture of muscle in the lower leg, dementia, and a recent intracapsular fracture of the right femur, was dependent on staff for mobility and required the use of a mechanical lift for all transfers. Despite these needs, the CNA attempted to reposition the resident in a Broda chair by pushing on a stuck lever, which caused the resident to tip forward and fall to the floor, sustaining a laceration to the mouth and a hairline fracture below the right knee. The facility's policies required staff to ask permission before repositioning residents and to ensure resident safety, dignity, and comfort during lifting and movement. Staff were also expected to be observed for competency in using equipment and to adhere to safe lifting techniques. However, the CNA involved had not completed documented skills competency reviews or new employee training, and there was no evidence of training or skills checks in the personnel file. Interviews with staff and family members confirmed that the CNA did not announce themselves or explain the repositioning process to the resident, contrary to facility policy and standard practice. Prior to the incident, concerns had been raised about the CNA moving too quickly with residents, and the CNA had been re-educated on the need to slow down and be gentle. Despite this, the CNA proceeded to reposition the resident without proper communication or technique, leading to the fall and injury. Multiple staff and family interviews corroborated that the CNA's actions were rushed and not in accordance with established procedures for resident safety.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of possible abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The incident involved a resident who made a threatening statement towards other residents during a smoke break. Despite staff intervention and documentation of the incident, the facility did not report the threat to the DHSS as required by their policy. The incident occurred when a resident became verbally aggressive during a smoke break, claiming ownership of a spot and threatening to harm others with a hammer. Staff intervened by redirecting the resident and separating the involved parties. The resident was then assisted to their room and put to bed, with no harm reported to any parties involved. However, the facility's staff did not document the reporting of this potential abuse to the DHSS, as required by state regulations. Interviews with staff revealed a lack of clarity regarding the reporting process for abuse allegations. Some staff members believed that the Director of Nursing (DON) was responsible for reporting to the state agency, while others assumed the incident did not constitute abuse. The Social Services Director and other staff members were unaware of the incident until days later, indicating a breakdown in communication and reporting procedures within the facility.
Resident Found with Marijuana and Pills, Facility Policies Not Followed
Penalty
Summary
The facility failed to maintain an environment free from potential hazards when a resident was found with marijuana and unknown pills on their person and in their room. The resident, who was admitted with diagnoses including lung cancer and COPD, was not documented as a smoker in their care plan or admission records. Despite being cognitively intact, the resident admitted to smoking marijuana on facility grounds for pain relief due to cancer, and had brought the substances from home. The facility's policies on incidents, smoking, and medication storage were not adequately followed. Staff did not document the resident as a smoker in the care plan, and there was a lack of education and intervention to prevent future occurrences. The Social Service Director and Business Office Manager found contraband items during a search of the resident's person and room, which included marijuana vape pens, a bottle of marijuana concentrate, and unmarked pills. These items were confiscated and given to the Administrator, but the staff failed to document the discovery of medication pills on the resident's person. Interviews with staff revealed a lack of awareness and communication regarding the resident's possession of marijuana and pills. The Director of Nursing was not fully involved in the investigation and only identified the medication as Tylenol and Advil. Staff were not informed about the resident having these items, and there was no documentation of the pills found on the resident. The facility's failure to adhere to its policies and ensure proper supervision and documentation contributed to the deficiency.
Failure to Provide Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who exhibited signs and symptoms of psychosocial distress. The resident, who had a history of anxiety disorder, dysthymic disorder, depression, and insomnia, displayed behaviors such as yelling, verbal abuse, and refusal of care. Despite these behaviors, the facility did not develop and implement resident-specific non-pharmacological interventions to address the resident's psychosocial needs. The resident's care plan included the use of antidepressant and antianxiety medications, but there was no evidence of a comprehensive behavioral health plan or regular psychological consultations. The facility's policies emphasized the importance of understanding the meaning behind resident behaviors and minimizing the use of psychoactive medications. However, the facility primarily relied on medication adjustments, such as increasing lorazepam and adding Depakote, to manage the resident's behaviors without exploring non-pharmacological interventions. The resident's behaviors, including verbal aggression and threats towards staff and other residents, were documented in nurse progress notes. Despite these ongoing issues, there was a lack of consistent involvement from the social services department and no documented psychological services or behavior management interventions. The facility's failure to address the resident's behavioral health needs contributed to the deficiency in providing necessary care and services.
Failure to Provide Adequate Social Services for Resident with Depression
Penalty
Summary
The facility failed to provide appropriate medically related social services for a resident with a history of depression, anxiety disorder, and dysthymic disorder. The Social Services Designee (SSD) did not adequately address or assist in finding the root cause of the resident's yelling, cursing behaviors, refusal of care, and general unhappiness living at the facility. The resident had a history of verbal altercations and outbursts, which were documented in the nurse's progress notes, but there was a lack of follow-up or intervention from the SSD. The resident's care plan included the use of antidepressant and antianxiety medication, behavioral health consults as needed, and monitoring for signs and symptoms of depression and anxiety. Despite these measures, the resident continued to exhibit distressing behaviors, including yelling at staff, refusing care, and making threats towards staff and other residents. The SSD did not document any follow-up or interventions after the resident expressed unhappiness with the facility and a desire to move to another city. Additionally, the SSD did not review the resident's progress notes to identify problems or provide necessary interventions. Interviews with facility staff revealed that the resident's behaviors were often related to smoking and the timing of smoke breaks. The resident expressed dissatisfaction with the facility and the staff's response to his needs, particularly during the evening shift. The SSD admitted to not receiving any training for her role and was unaware of her responsibilities in monitoring residents' behaviors and providing necessary interventions. The lack of appropriate social services and interventions contributed to the resident's ongoing distress and dissatisfaction with the facility.
Inadequate Infection Control Practices in Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) and inadequate hand hygiene practices during wound care for two residents. The facility did not have a policy for EBP, which is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) through targeted gown and glove use during high-contact resident care activities. Observations revealed that staff did not follow standard infection control practices, such as washing or sanitizing hands at appropriate times during wound care. Resident #1, who had multiple sclerosis, heart failure, and type two diabetes mellitus, was at risk for pressure ulcers and had three Stage 2 pressure ulcers. During wound care, a Licensed Practical Nurse (LPN) failed to change gloves or sanitize hands between measuring multiple wounds, potentially contaminating them with infectious materials. Additionally, the LPN did not perform hand hygiene upon completion of the task. Another observation showed that a corporate nurse and an LPN did not don gowns or change gloves between measuring wounds, further risking contamination. Resident #2, diagnosed with unspecified dementia, depression, hypertension, and type two diabetes mellitus with diabetic neuropathy, had a burn on the left thigh. During wound care, an LPN placed supplies on the bedside table without a barrier, did not change gloves or perform hand hygiene after removing a dressing, and potentially contaminated the treatment cart by placing used supplies back into it. Interviews with staff, including LPNs, a Registered Nurse (RN), and a Nurse Practitioner (NP), revealed a lack of knowledge about EBP and inconsistent practices regarding the use of personal protective equipment (PPE) and hand hygiene during wound care.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with multiple medical conditions, including multiple sclerosis, heart failure, and type two diabetes mellitus. The resident was at risk for pressure ulcers and had three Stage 2 pressure ulcers. The facility's policies required weekly skin assessments and wound tracking, but these were not consistently performed. The resident's care plan indicated a need for pressure-reducing devices and specific treatments, but there were lapses in documentation and communication regarding the resident's wounds. The nursing staff did not consistently document the resident's wounds or obtain treatment orders for all wounds. There were gaps in the nursing progress notes, with no documentation of the wound or treatment for several days. When documentation was present, it often lacked complete information about the wounds, such as size, location, and treatment orders. Observations revealed that the resident had multiple open areas on the buttocks, but there were no corresponding treatment orders in the Physician Order Sheet for these areas. Interviews with staff revealed inconsistencies in wound care practices and communication. Some nurses applied dressings without orders, and there was a lack of notification to the physician about new or worsening wounds. The Nurse Practitioner was not informed of all skin concerns, and there was confusion among staff about the appropriate treatment for the resident's wounds. The corporate nurse emphasized the importance of complete documentation and physician notification, but these practices were not consistently followed, leading to inadequate care for the resident's pressure ulcers.
Facility Lacks RN and DON Coverage
Penalty
Summary
The facility failed to ensure adequate registered nurse (RN) coverage and did not have a Director of Nursing (DON) available to fulfill necessary duties on a full-time basis. The previous DON had been providing routine floor coverage before resigning without notice, leaving the facility without a DON or RN. The facility's policy mandates sufficient qualified nursing staff to meet residents' needs and requires a registered nurse to serve as the DON on a full-time basis, except when waived. However, the facility was unable to meet these requirements, as evidenced by the absence of a DON or RN on staff and the reliance on advertisements to fill these positions. Interviews with various staff members, including the Business Office Manager, Administrator, and several nursing staff, confirmed the lack of a DON and RN coverage. The facility's daily staffing sheets showed inconsistent RN coverage, with the previous DON listed as working various shifts, including as a charge nurse and certified nursing assistant (CNA), before resigning. The Administrator acknowledged the absence of a DON and RN, stating that the facility was actively seeking to fill these positions through advertisements and potential contracts. The deficiency was identified during a survey, with the facility census at 38 residents.
Failure to Properly Manage Residents' Personal Funds
Penalty
Summary
The facility failed to manage and account for residents' personal funds as required by regulations. Specifically, the facility did not deposit residents' personal funds exceeding $50 into an interest-bearing account for two residents receiving Medicaid services. Additionally, the facility did not maintain an ongoing balance or provide reasonable access to funds for seven residents. The Business Office Manager (BOM) admitted that resident funds were kept in a locked safe in the Administrator's office, with only the Administrator and BOM having access. The funds were not kept in an interest-bearing account, despite the BOM's awareness of the requirement. During an observation, it was found that several residents had cash amounts documented on paper, but these amounts were not accurately reflected in the interest-bearing account as required. For instance, one resident had $73 in cash, but the paper balance showed $100.74, and another resident had $200 in cash with no interest-bearing account documentation. The facility's policy mandates that residents' personal funds over $50 for Medicaid recipients should be deposited in an interest-bearing account, but this was not adhered to, leading to a deficiency in managing residents' financial affairs.
Failure to Follow Hoyer Lift Transfer Orders
Penalty
Summary
The facility failed to ensure that residents were as free from accident hazards as possible by not adhering to physician orders for the safe transfer of a resident using a Hoyer lift. The facility's policy mandates that the Hoyer lift is a two-person operation and that any staff transferring a resident alone would face immediate termination. Despite this, an observation revealed that a nurse aide transferred a resident without using the Hoyer lift, instead assisting the resident to stand and pivot to a wheelchair and recliner without a gait belt. The resident involved had a history of traumatic subdural hemorrhage, monoplegia of the upper limb, and was non-ambulatory, requiring total dependence on staff for transfers using a Hoyer lift. The resident's care plan and physician orders specified the use of a Hoyer lift for all transfers, which was reinforced by an in-service training and a care plan meeting. However, the nurse aide believed the Hoyer lift order was PRN and proceeded with a manual transfer, contrary to the established orders and policy. Interviews with various staff members, including nurse aides, restorative aides, and the administrator, confirmed that the resident was to be transferred using a Hoyer lift as per physician orders. The staff acknowledged the requirement to follow these orders, yet the incident demonstrated a failure to comply, resulting in a deficiency related to accident hazards and supervision in the facility.
Failure to Administer Medications and Monitor Edema
Penalty
Summary
The facility failed to provide care per standards of practice for a resident with edema, resulting in increased edema, weight gain, and an inability to wear shoes. The resident, who had severe cognitive impairment and was not taking a diuretic, had a history of intracerebral hemorrhage, hemiplegia, seizures, and muscle weakness. The facility did not have a policy related to monitoring changes in condition, and staff failed to administer medications as ordered, monitor the resident as ordered, and notify and follow-up with the physician in a timely manner. The resident's care plan required staff to monitor and document any edema and notify the physician. However, the staff did not consistently check the resident's blood pressure as ordered and failed to document further entries related to the resident's edema or notify the clinic. Despite new orders to decrease amlodipine due to edema and monitor blood pressure, the resident's condition worsened, with significant weight gain and increased edema noted in subsequent evaluations. Interviews with staff revealed a lack of communication and follow-up regarding the resident's condition. Nurse aides reported the resident's legs had been swollen for months, but this was not communicated to the nurse. The LPN and ADON indicated that they would expect a response to a fax regarding a resident by the end of the day or would follow-up with a call, but this did not occur. The DON confirmed that the physician should be notified for increased edema and that staff should follow physician orders.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's policy mandates the presence of an RN for this duration unless waived, and the Director of Nursing (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. However, a review of the monthly work schedules for July, August, and September 2024 revealed multiple days where no RN was scheduled, indicating a breach of this requirement. Interviews conducted during the survey further highlighted the deficiency. An LPN mentioned uncertainty about the daily presence of an RN, while a Certified Medication Tech confirmed that although there was always a nurse working, it was unclear if an RN was available for the required hours. The facility's administrator acknowledged that the previous DON did not clock in or out due to being salaried, and currently, only two RNs were employed, with one working part-time every other weekend. This staffing situation contributed to the failure to meet the regulatory requirement of having an RN on duty for the specified hours.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that eight nurse aides completed a certified nurse aide (CNA) training program within four months of employment, as required by their policy. The policy mandates that all nursing assistants must complete the basic course and be certified within four months of employment. However, the review of the facility's records and the state agency CNA registry website revealed that none of the eight sampled nurse aides were certified within the stipulated time frame, with some aides having been employed for several years without certification. Observations and interviews further highlighted the deficiency. Nurse aides were observed providing direct care to residents despite not being certified. Interviews with the nurse aides revealed that they had attended CNA classes multiple times, but due to various reasons, such as the facility not setting up certification dates or instructors becoming unavailable, they were unable to complete the certification process. This situation persisted for several years for some aides, indicating a systemic issue in the facility's training and certification process. The facility's administrator acknowledged the issue, stating that nurse aides should be certified in a timely manner. However, the report does not mention any corrective actions or follow-up measures taken to address the deficiency at the time of the survey. The lack of certified nurse aides potentially compromises the quality of care provided to residents, as these aides are performing duties without the necessary certification and training.
Deficiency in Dietary Manager Qualifications
Penalty
Summary
The facility failed to employ sufficiently qualified staff in the food and nutrition services department, specifically in the role of the Dietary Manager. The Dietary Manager, who was hired in May 2024, did not possess the required certification or experience for the position. Despite being employed at the facility since 2005, the Dietary Manager had previously worked as an Activities Director and a nursing assistant, with no training or certification in food service management. The facility's policy on dietary services did not specify the required qualifications for the Dietary Manager position, and there was no documentation provided to confirm that the Dietary Manager met the minimum qualifications. During interviews, the Dietary Manager acknowledged the lack of training or certification in food service management. The facility's Administrator also recognized the need for the Dietary Manager to have some training and was aware of the educational requirements needed for the role. The Administrator mentioned plans to enroll the Dietary Manager in educational classes to address the deficiency, but at the time of the survey, these actions had not yet been implemented.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of unsanitary conditions in the kitchen and food storage areas. The kitchen floor was found to have debris, and various surfaces, including stackable containers, the stove, and steam table handles, were covered with a yellow greasy residue. Additionally, the handles of the three-compartment refrigerator were noted to be brownish tinged and slick to the touch. The Dietary Manager admitted to cleaning the kitchen herself without a cleaning list or assignment sheet, indicating a lack of structured cleaning protocols. Further observations revealed that food preparation areas were not maintained in a sanitary condition. Debris was present on food preparation tables, and a box fan with brown, fuzzy debris was blowing towards these tables. A Dietary Aide was observed handling trash and then rolling out trash bags on a food prep area without immediate cleaning or sanitization. Flies were seen landing on kitchen serving items and the steam table, and doors to various areas, including the outside, were left open. Staff were observed handling diet cards with debris on them and then touching food contact areas without proper sanitation. The facility also failed to maintain proper food storage temperatures. The three-door refrigerator was observed with an exterior thermometer reading 50 degrees F and an interior thermometer reading 48 degrees F, with no temperature entries logged by staff. Food items such as ham, turkey breast, and mayonnaise were stored at temperatures above the recommended range. Additionally, spoiled and improperly stored food items were found in the refrigerator and freezer, including undated and cling-wrapped items with visible spoilage. The Dietary Manager and Registered Dietician acknowledged the issues with temperature monitoring and food storage, but the facility's practices did not align with their stated policies.
Failure to Submit Timely Payroll-Based Data to CMS
Penalty
Summary
The facility failed to submit payroll-based data to the Centers for Medicare and Medicaid Services (CMS) in a timely manner, as required. The facility, with a census of 38, did not submit the Payroll Based Journal (PBJ) Staffing Data Report for the fiscal year quarter two of 2024, covering the period from April 1 to June 30, 2024. During an interview, the Administrator, who assumed her position in July, stated that she had only recently started the PBJ for the months of July, August, and September. She discovered that the report had not been completed for some time and was unable to enter data for the previous period. The Administrator was unaware of who was previously responsible for submitting the report.
Failure to Implement Effective QAPI Plan
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) plan. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a policy or procedure related to a comprehensive QAPI Plan. The facility lacked documentation of Performance-Improvement-Plans (PIPs) or evidence of good-faith attempts to correct identified deficient practices. Additionally, there was no current identified infection preventionist participating in the QAPI process, nor was there documentation of medical director input. During an interview, the Administrator admitted the inability to find any policy or procedure for QAPI and was unable to provide documentation of PIPs for any items. The facility also failed to conduct weekly reviews, including documentation and measurements, for problems identified by QAPI. The facility census was 38 at the time of the survey.
Deficiency in QAA Committee Documentation and Participation
Penalty
Summary
The facility failed to maintain documentation of a functioning Quality Assessment and Assurance (QAA) Committee that met at least quarterly with the required members. The facility, with a census of 38, did not provide a policy regarding the QAA Committee. Records showed that staff lacked documentation to confirm that the QAA Committee met quarterly with the necessary members. Additionally, the facility did not have an Infection Preventionist to participate in the QAA Committee, and the medical director did not regularly attend the QAA Committee meetings. During an interview, the Administrator acknowledged the absence of an infection preventionist and was unable to determine the frequency of the medical director's participation in the QAA Committee.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not have a process in place to monitor for Legionella, a severe form of pneumonia, despite having a policy that outlined the necessary steps for prevention. The Maintenance Supervisor admitted to not conducting any monitoring for Legionella, and there was no documentation available to show compliance with the Legionella policy. Additionally, the facility's infection control measures were inadequate, as staff were observed not following proper respiratory hygiene and hand hygiene protocols. A Restorative Aide was seen coughing in the hallway without wearing a mask or covering their mouth, despite having pneumonia, and continued to work with residents without taking appropriate precautions. The facility also failed to adhere to its linen management policy, which required clean linens to be covered and protected from contamination. Observations revealed that clean resident clothing was transported on uncovered carts, and staff confirmed that this was the standard practice. Furthermore, the facility did not follow proper procedures for wound care, as supplies were placed directly on residents' bedside tables without a clean barrier, potentially contaminating the supplies and the residents' environment. This was observed in the care of two residents, both of whom had pressure ulcers and required wound care. The facility lacked a policy for Enhanced Barrier Precautions (EBP), an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. Staff interviews indicated a lack of understanding and implementation of EBP, with inconsistent use of personal protective equipment (PPE) during high-contact resident care activities. Observations showed that staff did not don gowns during wound care for residents with pressure ulcers and Foley catheters, and there was no signage or PPE cart available to indicate the need for EBP. The Administrator acknowledged that staff were likely unaware of what EBP entailed, further highlighting the facility's failure to implement effective infection control measures.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a comprehensive and current antibiotic log for residents with active infections. The facility's policy on antibiotic stewardship was not adhered to, as there was no ongoing tracking of antibiotic use, and the care plans for two residents on antibiotics were incomplete. The facility's infection control binder contained outdated and incomplete records, with missing information for several months, indicating a lack of proper monitoring and documentation. Resident #30, who was admitted with diagnoses including intraspinal abscess and osteomyelitis, was on an antibiotic regimen. However, the resident's care plan did not include details related to antibiotic therapy, and the resident was not listed in the facility's infection control logs for July and August 2024. Similarly, Resident #15, who had undergone major orthopedic surgery and was receiving multiple antibiotics for a foot infection, did not have antibiotic therapy included in their care plan. Despite being on active antibiotic orders, the resident's treatment was not adequately tracked or documented. Interviews with facility staff revealed a lack of clarity and responsibility regarding the antibiotic stewardship program. The Director of Nursing and other staff members were unaware of the deficiencies in tracking antibiotic use, and there was confusion about who was responsible for the program. The previous Director of Nursing had managed the program, but after their departure, the responsibility was not clearly assigned, leading to lapses in monitoring and documentation of antibiotic use and infection control.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a certified infection preventionist (IP) responsible for the infection prevention and control program (ICPC). The facility, with a census of 38, did not have a policy related to the IP position. During interviews, the Administrator was unsure who was monitoring infections, despite having taken the infection preventionist course without completing the test. It was suggested that an LPN might be monitoring infections, but the LPN confirmed they did not have IP certification and were not tracking infections. The previous Director of Nursing (DON) and Assistant Director of Nursing (ADON) had been responsible for monitoring, but no current staff member was identified as in charge of infection prevention. Another LPN also confirmed they were not monitoring any infection program. The Administrator acknowledged the need for a staff member to monitor and track antibiotics, infections, and wounds.
Failure to Complete Criminal Background Checks for New Hires
Penalty
Summary
The facility failed to develop and implement effective abuse prevention policies, specifically in the area of staff screening through Criminal Background Checks (CBC). This deficiency was identified when the facility did not follow up on requested CBCs for four staff members, including two Nurse Aides, a Restorative Aide, and a Certified Medication Technician. The facility's policy, dated 09/09/13, mandates that all potential new hires must have a background check initiated before employment and that no new employee should have direct contact with residents until this step is completed. However, the personnel records for these staff members showed that while CBCs were requested, there was no documentation of their completion or findings. Interviews with the Business Office Manager and the Administrator revealed a lack of awareness and oversight regarding the completion of these checks. The Business Office Manager, who started in August 2024, acknowledged the absence of completed CBCs for the four staff members and had created a checklist to ensure compliance with hiring procedures. The Administrator expressed an expectation that all required documentation and CBCs be completed before new employees work with residents, indicating a gap between policy expectations and actual practice.
Deficiency in Code Status Management
Penalty
Summary
The facility failed to ensure the timely and accurate identification of code status for residents, which is crucial for determining whether a resident wishes to receive cardiopulmonary resuscitation (CPR). This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not have a process in place to manage code status effectively. Specifically, there were no physician orders related to code status for three residents, and conflicting code status information was found in the medical records of two other residents. For Resident #36, the face sheet indicated a do not resuscitate (DNR) status, but the care plan did not reflect this choice, and there were no physician orders confirming the code status. Similarly, Resident #30's face sheet showed a full code status, but the care plan incorrectly listed the resident as DNR, and there were no physician orders to confirm the code status. Resident #3's documentation was inconsistent, with a DNR sticker on the chart but no corresponding physician order. Additionally, Resident #11's records showed conflicting information, with a face sheet indicating full code status, but the physician order sheet listed DNR. Resident #26's documentation also had discrepancies, with a DNR sticker on the chart but a physician order for full code. Interviews with staff, including a Nursing Aide, LPN, DON, and the Administrator, highlighted inconsistencies in the process of documenting and verifying code status, indicating a lack of a standardized procedure for managing this critical information.
Failure in Medication Administration and Destruction
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by the failure to obtain and administer medications as ordered for a newly admitted resident. This resident, who had severe cognitive impairment and multiple cardiovascular conditions, did not receive prescribed medications including amlodipine, magnesium oxide, and potassium chloride for nine consecutive days. The staff documented that the medications were not available but failed to notify the physician or document any progress notes regarding the unavailability of these medications. Additionally, the facility did not have an effective system for the timely destruction of medications that could not be returned to the pharmacy. Observations revealed a locked cabinet containing numerous medication cards waiting to be destroyed, and the facility lacked a policy regarding the disposal or destruction of medications. Interviews with staff indicated that the destruction of medications had not occurred for over a month, and there was no clear schedule for when this should be done. The facility's medication destruction log showed that medications for multiple residents were waiting to be destroyed for various reasons, including expiration and discontinuation by physicians. Despite the presence of a medication destruction log, the process was not being carried out in a timely manner, as confirmed by interviews with staff who were unsure of the destruction schedule. The administrator acknowledged that the destruction should occur weekly or monthly, but this had not been consistently implemented.
Failure to Act on Pharmacy Recommendations and Conduct Monthly Drug Reviews
Penalty
Summary
The facility failed to ensure that pharmacy consultant recommendations for gradual dose reductions (GDR) were acted upon for a resident who was prescribed psychoactive medications. Specifically, for one resident with diagnoses including anxiety disorder, depression, schizoaffective disorder, and Alzheimer's disease, the facility did not attempt a GDR for the antipsychotic medication risperidone, despite pharmacy recommendations to decrease the dosage. The physician did not respond to or sign the pharmacy recommendation sheets for GDRs dated July and August 2024. Additionally, the facility did not complete monthly drug regimen reviews (MMRs) for three residents. One resident with diagnoses of unspecified dementia, insomnia, and dizziness had no documentation of an MMR completed by a pharmacist for August and September 2024. Another resident with heart disease, heart failure, insomnia, unspecified dementia, and anxiety also had no record of MMRs. A third resident with arthritis, a history of depression, and seizures lacked an MMR for August 2024. Interviews with facility staff revealed confusion regarding responsibility for MMRs and GDRs. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unsure of who was responsible for these tasks, with the DON suggesting it could be the responsibility of the ADON or medical records. The Licensed Practical Nurse (LPN) indicated that the DON was responsible for MMRs and physician notification for GDRs. The facility administrator confirmed that medications should be reviewed by the pharmacist and physician monthly.
Failure to Provide Bed Hold Policy for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy for a resident who was transferred to the hospital on two separate occasions. The resident, who had Alzheimer's disease and vascular dementia, was admitted to the hospital and discharged back to the facility twice. On both occasions, the facility did not document providing written bed hold information to the resident or their responsible party, nor did they have a copy of the bed hold policy provided to them. This lack of documentation and communication regarding the bed hold policy was identified during a review of the resident's medical records and hospital visit summaries. Interviews with facility staff revealed a lack of clarity and responsibility regarding the bed hold policy. The LPN indicated that social services were responsible for bed holds, but was unsure if a copy needed to be provided to residents upon discharge or transfer. The ADON stated that staff should have bed holds signed and a copy made for all transfers. The Administrator acknowledged that nurses should complete and send bed holds with residents when transferred, and that the social worker should follow up and maintain a log of bed holds, which had not been done. This lack of adherence to the bed hold policy resulted in the deficiency identified by the surveyors.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with multiple complex medical conditions including congestive heart failure, chronic kidney disease, chronic respiratory failure, type 2 diabetes mellitus, lymphedema, atrial fibrillation, and chronic obstructive pulmonary disease, did not have a baseline or comprehensive care plan documented in their medical record. This omission was identified during a review of the resident's records, which showed that the resident arrived from the hospital via wheelchair with oxygen cannisters, but no care plan was completed. Interviews with facility staff, including two LPNs and the Administrator, revealed that baseline care plans should be completed within the first 24 hours of admission and be accessible in the resident's chart to assist with care needs. However, in this case, the staff did not document the completion of the required care plan, leading to a deficiency in meeting the resident's immediate needs upon admission.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for two residents. The staff did not document full regular assessments of wounds, update care plans, notify physicians in a timely manner of new or changing wounds, or ensure that physician's orders were followed. For Resident #30, there were multiple instances where wounds were not fully assessed or documented, and new wounds were not reported to the physician promptly. The resident had several wounds, including on the coccyx, ankle, and scrotum, which were not consistently documented or treated according to physician orders. Resident #36 also experienced inadequate wound care. The resident had a history of Alzheimer's disease and vascular dementia and was at risk for pressure ulcers. The staff failed to document full assessments of the resident's wounds, including a blister on the right heel and an open area on the right buttock. The facility did not have complete documentation of wound assessments for the months of July and August 2024, and the care plan was not updated to reflect new skin areas. Interviews with facility staff, including the DON, ADON, and LPNs, revealed a lack of understanding and execution of proper wound care procedures. The DON admitted to being new and still learning about care plans, while the Administrator was unsure if skin assessments were completed for all residents. The facility's failure to adhere to its own policies and procedures for wound management and care planning contributed to the deficiencies observed by surveyors.
Failure to Ensure Consistent Use and Monitoring of Hand Splint
Penalty
Summary
The facility failed to ensure that a resident received appropriate care to maintain or improve range of motion (ROM) due to inconsistent use and monitoring of an ordered hand splint. The resident, who was admitted with diagnoses including intracerebral hemorrhage, hemiplegia, seizures, and muscle weakness, was noted to have developed a left-hand contracture. A Nurse Practitioner recommended and ordered a left-hand brace for the contracture, but the facility did not update the resident's care plan to include this order. Additionally, the brace was not documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and there were no further progress notes or updates in the resident's restorative notes since the initial assessment. Observations revealed that the resident did not consistently wear the brace, and it was often found off the resident's hand. Interviews with staff indicated a lack of clear responsibility and communication regarding the application and monitoring of the brace. The Restorative Aide mentioned that nurses were responsible for assistive device orders, while the Licensed Practical Nurse stated that the brace should be included in the orders and monitored by a nurse. The Assistant Director of Nursing and the Director of Nursing both emphasized the importance of including such orders in the care plan and monitoring them, but this was not done, leading to the deficiency.
Improper Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide proper incontinence care for two residents, leading to potential infection risks. Observations revealed that nursing aides did not perform hand hygiene before donning gloves and failed to change gloves or wash hands during the care process. For Resident #12, aides did not cleanse the genital area and used the same wipe multiple times without changing gloves, which is against the facility's policy and nursing standards. For Resident #6, similar deficiencies were observed. The staff did not clean the urethral meatus and used the same wipe multiple times to clean the resident's gluteal area, again without changing gloves or performing hand hygiene. This improper technique was noted despite the resident's severe cognitive impairment and dependency on staff for personal hygiene. Interviews with staff, including a Nursing Assistant, LPN, and the Director of Nursing, confirmed that the expected procedure was not followed. They acknowledged that incontinence care should be performed every two hours, with proper hand hygiene and glove changes, and that residents should be cleansed from front to back using one wipe per swipe. However, the Director of Nursing was unsure of the facility's specific incontinence care procedure, indicating a lack of clarity and adherence to established protocols.
Failure to Implement Dietary Recommendations for Resident
Penalty
Summary
The facility failed to ensure that all residents received the recommended interventions to maintain acceptable nutritional status, specifically for one resident identified as experiencing weight loss. The resident, who had diagnoses including coronary artery disease, dementia, high blood pressure, and heart disease, was on hospice services and had a regular diet. The Registered Dietitian (RD) recommended larger meal servings and a daily dietary supplement, Carnation Instant Breakfast (CIB), for weight maintenance. However, these recommendations were not included in the resident's care plan, and there was no physician order for the CIB. Interviews with facility staff revealed a lack of clarity and communication regarding the implementation of the RD's recommendations. Nursing staff were responsible for notifying the physician and documenting orders in the Physician Order Sheet (POS), but this was not done. The dietary staff were unaware of the resident's need for CIB, as the resident was not listed on the CIB list used by the dietary department. The RD communicated her recommendations verbally and through progress notes, but there was confusion about whose responsibility it was to ensure these were implemented. The Director of Nursing (DON) and the Administrator were also unclear about the process for documenting and implementing new dietary recommendations. The DON expected nursing staff to obtain and document orders, while the Administrator emphasized the need for timely documentation and implementation of new orders. The lack of a clear policy and communication between departments led to the failure to provide the recommended dietary supplement to the resident, resulting in a deficiency in maintaining the resident's nutritional status.
Failure to Provide Physician Orders for CPAP Use
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident using a CPAP machine, as there were no physician orders obtained for its use and care. The resident, who was admitted with conditions including diabetes, high blood pressure, atrial fibrillation, obesity, and chronic kidney disease, was observed using a CPAP machine for sleep apnea. However, the facility did not have a policy related to CPAP use, and the resident's care plan did not include any information regarding the CPAP machine. Additionally, the September 2024 Physician's Order Sheet and Medical Administration Record lacked documentation of an order for the CPAP machine or its settings. Interviews with staff revealed a lack of awareness and training regarding the CPAP machine. A nursing assistant was unsure if a physician order was required and had not received any education on the machine. An LPN confirmed the absence of a physician's order and noted that such an order should include the diagnosis, settings, and care instructions for the CPAP machine. The Director of Nursing and the Administrator both acknowledged the need for physician orders and care planning for CPAP use, indicating a systemic oversight in ensuring proper respiratory care for the resident.
Failure to Limit PRN Psychotropic Medications and Attempt GDRs
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic PRN medications, which should be limited to fourteen days unless evaluated by a physician. One resident, diagnosed with Alzheimer's disease and vascular dementia, was prescribed clonazepam without an end date and received the medication 27 times in July, exceeding the 14-day limit. The order was eventually discontinued 29 days after it was written. Additionally, a new order for olanzapine was issued without a diagnosis or end date, although it was not administered. The facility also failed to attempt a gradual dose reduction (GDR) for another resident who was on psychotropic medications. This resident, diagnosed with unspecified dementia and other conditions, had been on quetiapine since July of the previous year and January of the current year, with no documented attempts at GDR. The facility's policy requires GDRs and non-pharmacological interventions before continuing psychotropic medications, but these were not documented for this resident. Interviews with facility staff revealed a lack of clarity and responsibility regarding medication reviews and GDRs. The Assistant Director of Nursing was unsure who was responsible for these reviews, and the Director of Nursing was uncertain about the need for expiration dates on PRN psychotropic medications. The Administrator acknowledged that PRN psychotropic medications should have a 14-day end date, but this was not consistently implemented.
Deficient Documentation of Resident Transfers
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation related to changes in their conditions and subsequent hospital transfers. For one resident, the facility did not document a care plan or nurses' progress notes regarding the transfer to and return from the emergency room. The resident was taken to the emergency room due to poor lab results and returned to the facility for compassionate care at the request of the resident and their Power of Attorney. Another resident, diagnosed with Alzheimer's disease and vascular dementia, was transferred to a hospital's inpatient psychiatric unit due to a major neurocognitive disorder. The facility's records lacked documentation of the resident's condition prior to the hospital admission, including assessment findings, the reason for the transfer, and notification to the physician. The nursing progress notes did not include any entries from the time leading up to the hospital admission. Interviews with facility staff, including LPNs, the Assistant Director of Nursing, the Director of Nursing, and the Administrator, revealed that there was an expectation for staff to document changes in residents' conditions, reasons for hospital transfers, and notifications to physicians and families. However, the facility did not have a policy related to the accuracy of or documentation in resident records, which contributed to the deficiencies observed.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent place that was readily accessible to residents and visitors. The posted information did not include the name of the facility, nor did it show the total and actual number of hours worked for each category of licensed and unlicensed staff directly responsible for resident care per shift. Observations on multiple days revealed that the postings were located on a bulletin board at the nurses' station, which was not easily accessible to residents. Additionally, the postings lacked the names of the registered nurse (RN), Director of Nursing (DON), and Assistant Director of Nursing (ADON), and only included first names of staff working in each position. Interviews conducted during the survey indicated a lack of awareness among staff regarding the responsibility for posting the daily schedule and the specific information required on the postings. An LPN interviewed was unaware of who was responsible for the postings and what information needed to be included. The facility administrator acknowledged that the facility should have a posting that included the total hours worked available for residents and visitors to view. The facility also did not provide a policy related to the posting of staffing hours.
Staff Yelling and Cursing in Presence of Resident
Penalty
Summary
The facility failed to ensure all residents were treated with dignity and respect when a staff member yelled and cursed in the presence of residents. Specifically, on the night of 04/09/24, CNA A was observed yelling and using inappropriate language towards another staff member, NA B, in the presence of Resident #1. Resident #1, who has severe cognitive impairments including Alzheimer's disease and dementia with behavioral disturbances, was being assisted by CNA A with a gait belt. NA B advised CNA A to be careful due to the resident's need for a wheelchair, to which CNA A responded with profanity, stating they had been doing the job for 13 years and did not need to be told how to do it. Multiple staff members, including NA D and LPN C, corroborated the incident, noting that CNA A's behavior was inappropriate and undignified in the presence of the resident. Resident #1's care plan indicated severe cognitive impairment and a need for staff assistance with emotional, intellectual, physical, and social needs. The resident also had a communication problem related to a hearing deficit and no longer used hearing aids. The incident occurred when CNA A, who appeared irritated upon arrival, was assisting the resident from the break room to their room. Despite being advised to use a wheelchair for the resident's safety, CNA A insisted on using a gait belt and responded aggressively to NA B's caution. The Director of Nursing and the Administrator acknowledged that such behavior was inappropriate and undignified around residents.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs by not adequately monitoring blood pressure as ordered for one resident who received medications to help control blood pressure. The resident, who had diagnoses including atrial fibrillation, heart failure, and high blood pressure, had orders to administer metoprolol and amlodipine and to record blood pressure each shift. However, staff did not document monitoring the resident's blood pressure on the second shift on eight dates and did not document monitoring on the third shift at all in January 2024. Interviews with various staff members revealed inconsistencies in understanding and following the orders for blood pressure monitoring, and there was no policy in place regarding following physician's orders and monitoring with the administration of medications. The Director of Nursing and Administrator acknowledged that there were missed shifts where blood pressure was not taken as ordered. The facility did not have staff reviewing the Medication Administration Records (MARs) and Treatment Administration Records (TARs) to ensure that medications and orders were being followed correctly. This lack of oversight and adherence to physician's orders led to the deficiency in the resident's care, as the necessary blood pressure monitoring was not consistently performed and documented.
Failure to Specify Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs when staff did not specify a diagnosis for the use of a psychotropic medication for one resident. The resident, who had diagnoses of Alzheimer's disease and unspecified dementia with behavioral disturbances, was prescribed Ativan for agitation without a documented diagnosis justifying its use. The resident's care plan included administering medications as ordered and monitoring for side effects and effectiveness, but the specific diagnosis for Ativan was not documented in the resident's records or progress notes. Interviews with facility staff revealed that the Ativan was administered about twice or three times a day, and the family nurse practitioner had reinstated the medication for the resident's confusion and wandering behaviors. However, the Director of Nursing and Administrator acknowledged that the staff had not documented the diagnosis for Ativan administration and had only recently started asking staff to document what interventions were tried before administering the medication. The facility did not provide a policy regarding psychotropic medications, contributing to the deficiency.
Staff Yelling and Cursing in Presence of Resident
Penalty
Summary
The facility failed to ensure all residents were treated with dignity and respect when a staff member yelled and cursed in the presence of residents. Specifically, CNA A was reported to have yelled and used profanity towards NA B in front of Resident #1, who has severe cognitive impairments including Alzheimer's disease and dementia. The incident occurred when CNA A was assisting the resident with a gait belt, and NA B advised caution due to the resident's unsteady condition. CNA A responded aggressively, stating they had been doing the job for 13 years and used inappropriate language. Multiple staff members, including NA B, NA D, and LPN C, provided written statements and interviews corroborating the incident. They reported that CNA A appeared irritated and rushed, and despite being advised to use a wheelchair for the resident's safety, CNA A insisted on using the gait belt. The Director of Nursing and the Administrator acknowledged that such behavior was inappropriate and undignified. The resident's care plan indicated a need for staff to communicate respectfully and consider the resident's cognitive decline and communication problems, which was not adhered to during this incident.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency. Specifically, it was reported that a Certified Nurse Aide (CNA A) cursed at two residents, but the facility did not report this allegation to the state within the required timeframe. The incident was reported to the Director of Nursing (DON) six days after it occurred, and the facility did not self-report the allegation of abuse to the Department of Health and Senior Services (DHSS). Resident #1, who has diagnoses including unspecified dementia with behavioral disturbances, insomnia, pain, blindness in one eye, and atherosclerosis of the aorta, was one of the residents involved. The resident's care plan indicated total dependency on staff for daily living activities and a potential for physical aggression and verbal abuse towards staff. Despite these vulnerabilities, the facility did not report the alleged abuse in a timely manner. Resident #2, who has diagnoses including metabolic encephalopathy, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, pneumonia, acute respiratory failure with hypoxia, major depressive disorder, seizures, hallucinations, contracture, and unspecified psychosis, was the other resident involved. The resident's care plan also indicated total dependency on staff for daily living activities and a potential for verbal aggression. Similar to Resident #1, the facility failed to report the alleged abuse within the required timeframe, and the investigation was delayed.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs by not adequately monitoring blood pressure as ordered for one resident who received medications to help control blood pressure. The resident, who had diagnoses including atrial fibrillation, heart failure, and high blood pressure, had physician's orders to administer metoprolol and amlodipine and to record blood pressure each shift. However, staff did not document monitoring the resident's blood pressure on the second shift on eight dates and did not document monitoring on the third shift at all in January 2024. Additionally, the facility did not have a policy regarding following physician's orders and monitoring with the administration of medications. Interviews with various staff members, including LPNs and the Director of Nursing, revealed inconsistencies in the understanding and execution of the blood pressure monitoring orders. Some staff members believed that blood pressure should be checked each shift if ordered, while others were unsure if the orders were being followed. The Director of Nursing and Administrator acknowledged that there were missed shifts where blood pressure was not monitored as ordered. The lack of a policy and oversight in reviewing MARs and TARS contributed to the deficiency in ensuring the resident's drug regimen was free from unnecessary drugs.
Failure to Specify Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs when staff did not specify a diagnosis for the use of a psychotropic medication for one resident. The resident, who had diagnoses of Alzheimer's disease and unspecified dementia with behavioral disturbances, was prescribed Ativan for agitation without a documented diagnosis justifying its use. The resident's care plan included administering medications as ordered and monitoring for side effects and effectiveness, but it did not specify a diagnosis for the Ativan prescription. Interviews with staff revealed that the Ativan was administered about twice or three times a day, and there was no documentation of a diagnosis for its administration. The Family Nurse Practitioner reinstated the Ativan as needed for the resident, who exhibited confusion and wandered into other residents' rooms. The Director of Nursing and Administrator acknowledged that the Family Nurse Practitioner reviewed and made changes to the resident's medications and that they had been monitoring behaviors and completing medication changes. However, the facility did not provide a policy regarding psychotropic medications, and there was no documentation of non-pharmacological interventions being tried before administering the Ativan.
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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