Ascend At Aurora
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Missouri.
- Location
- 1700 South Hudson Avenue, Aurora, Missouri 65605
- CMS Provider Number
- 265182
- Inspections on file
- 26
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ascend At Aurora during CMS and state inspections, most recent first.
Two residents at risk for pressure ulcers did not receive timely and consistent skin assessments, wound measurements, documentation, or care planning in accordance with facility policy and professional standards. One resident was admitted with a documented Stage III pressure ulcer and required pressure-reducing devices and ulcer care, yet the admission care plan omitted the ulcer, no admission skin assessment was documented, early notes of buttock excoriation lacked measurements and notifications, and the first detailed wound assessment and treatment orders occurred days later, with gaps in ongoing wound documentation as the ulcer worsened. Another resident, identified on the MDS as at risk for pressure ulcers and ordered barrier cream for prevention, had bumps on the bottom noted on a bath assessment without nurse sign-off, was later reported by family to have two hospital-identified bed sores with MRSA, and on readmission had shearing and blanchable erythema documented without a wound assessment, new orders, or care plan updates. Staff interviews revealed that admission and weekly skin assessments, weekly wound rounds, and immediate assessment and notification for new open areas were expected but not consistently performed, and leadership acknowledged uncertainty about the electronic system, lack of audits, and incomplete weekly wound monitoring after a change in nursing leadership.
A resident with documented allergies to beef and other foods was admitted with cognitive impairment and required supervision for eating, but their food allergies were not incorporated into the diet order or initial care plan, and no special nutritional needs were indicated. Although the face sheet and admission assessment listed multiple allergies, the POS reflected only a regular diet, and staff from nursing and dietary relied on diet orders and dietary cards that were incomplete or inaccurate. Two conflicting dietary cards were created for the resident, one listing allergies and one without, and the Kitchen Manager used the card that did not list allergies, resulting in the resident being served a beef taco. The resident consumed the beef, later developed vomiting, diarrhea, and unresponsiveness, and was transferred to the hospital, where documentation identified an allergic reaction to beef after eating at the facility.
Two residents' controlled medication cards containing narcotics went missing, and staff, including the DON and a CMT, signed documentation indicating the medications were destroyed without actually witnessing or performing the destruction. Required procedures for handling, counting, and documenting controlled substances were not followed, resulting in misappropriation of resident property.
Two residents' narcotic medications were discovered missing, and although staff recognized this as misappropriation of property, the DON and Administrator delayed reporting the incident to the state agency. Despite facility policy and staff understanding that such events should be reported within hours, the misappropriation was not reported until several days after discovery.
The facility did not adequately promote or facilitate resident self-determination by failing to support resident choice, as required by regulations.
The facility failed to maintain an effective infection prevention and control program, as staff did not use appropriate PPE or perform proper hand hygiene. A resident with an indwelling medical device did not have EBP signage, and staff did not wear gowns and gloves as required. Additionally, staff failed to follow hand hygiene protocols during perineal care for three residents, increasing the risk of infection transmission. Interviews revealed a lack of awareness and understanding of EBP and hand hygiene protocols among staff.
A non-verbal resident dependent on staff for personal needs was subjected to mental abuse by a CNA, who made derogatory comments intended to upset the resident. Multiple staff members witnessed the resident's distress and reported the incidents, but the facility failed to document and investigate the abuse promptly, leading to a finding of immediate jeopardy.
A resident was administered a fentanyl patch and hydrocodone-APAP without orders, resulting in significant side effects and hospitalization. The error occurred because the physician wrote orders for multiple residents on the same piece of paper, and the nurse misread the orders. The resident experienced seizures, high blood pressure, and low blood oxygen levels, necessitating emergency medical intervention and hospitalization.
The facility failed to designate a full-time DON since February 2024, leaving the nursing staff without proper oversight and guidance. Despite attempts to fill the position, the facility remains without a DON, impacting the continuity of care and administrative responsibilities.
The facility failed to properly store and label food, maintain clean non-food contact surfaces, and sanitize dishes according to requirements. Observations revealed unlabeled and undated food items, peeling paint, and missing floor tiles in the kitchen. Staff interviews confirmed inconsistent adherence to policies and lack of proper sanitization due to missing equipment.
The facility failed to review and update the comprehensive facility assessment annually, with the last review documented in 2020. The new Administrator and Regional Corporate Clinical Staff confirmed that the assessment had not been reviewed since then, potentially delaying necessary services for residents. The facility census was 60.
The facility failed to maintain an effective infection control program by not adhering to its policy for monitoring and preventing Legionella bacteria in the water system and not implementing Enhanced Barrier Precautions (EBP) for residents with wounds, catheters, or other indwelling medical devices. Staff were not trained or aware of EBP protocols, and there was no documentation or regular flushing of water outlets in empty rooms.
The facility failed to implement an effective antibiotic stewardship program by not maintaining a current and ongoing antibiotic log of residents with active infections. The ADON/IP did not keep a detailed log or evaluate antibiotic use trends, and the facility's provided list of residents on antibiotics lacked comprehensive tracking. Interviews confirmed that the IP should be responsible for monitoring antibiotic use, which was not being done.
The facility failed to maintain a comfortable temperature range of 71 to 81 degrees Fahrenheit, affecting ten residents. Observations showed temperatures between 78 to 84 degrees Fahrenheit, causing discomfort for residents with conditions like multiple sclerosis and COPD. The facility lacked a policy for monitoring temperatures, and staff relied on opening windows and providing fans to address complaints.
The facility failed to follow their abuse prevention policy by not requesting a Criminal Background Check (CBC) or Family Care Safety Register (FCSR) check prior to an LPN having contact with residents. The LPN was hired and started working without the required checks, which were only completed months later. Interviews confirmed that the hiring process should include these checks and that no employee should have contact with residents until they are completed.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. One resident's care plan did not include oxygen use, another's did not reflect vaping during smoke breaks, and a third's did not address wound care, despite these needs being documented and observed.
The facility failed to care plan the use of side rails and obtain informed consent for their use for two residents, and did not complete gap measurements for installed side rails for three residents. Observations and interviews revealed that the residents had severe cognitive impairments and required assistance for bed mobility and transfers, yet their care plans did not address side rail use, and no assessments or measurements were documented. Staff interviews indicated a lack of clarity and responsibility regarding the assessment, installation, and maintenance of side rails.
A resident with severe cognitive impairment on a pureed diet received a dessert that was too thin and drinkable through a straw. The dietary aide used apple juice instead of milk, against the facility's policy, resulting in improper consistency. Staff interviews confirmed the deviation from the recipe and policy.
The facility failed to notify two residents and/or their representatives in writing of a transfer or discharge to a hospital, including the reasons for the transfer. Interviews with staff revealed that while medical information was sent with the residents, written notices were not provided. The Administrator confirmed that staff should send a transfer letter when sending a resident to the hospital.
The facility failed to provide bed hold policy information to residents and/or their representatives when two residents were transferred to the hospital. Staff interviews revealed that the facility had not been sending bed hold notices for about a year, despite the policy requiring it.
The facility failed to ensure proper communication and collaboration with the dialysis center for a resident requiring hemodialysis. Staff did not consistently send or receive dialysis communication forms, nor did they follow up when forms were not returned, leading to a lapse in care continuity.
The facility failed to ensure a resident received necessary behavioral health care and services for depression. Despite the resident's diagnoses and signs of depression, the facility did not care plan for the resident's depression or follow up with social services. Staff interviews revealed a lack of communication and follow-up, and the resident expressed feelings of sadness and a desire to talk to someone about their feelings.
A resident had an ongoing PRN order for alprazolam without physician review and justification beyond the initial 14-day period. Facility staff, including the ADON and medical director, were unaware of the 14-day limit for PRN psychotropic medications, leading to a deficiency in medication management.
Failure to Assess, Document, and Care Plan for Pressure Ulcers and Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care and prevention consistent with its own policy and professional standards for two residents. The facility’s skin integrity policy required an admission skin condition and pressure ulcer risk assessment, weekly skin and wound assessments by licensed nurses, daily CNA skin observations with prompt reporting of changes, timely documentation of initial ulcer observations, and immediate notification of the resident, representative, and physician at the earliest sign of a pressure ulcer. For Resident #3, the comprehensive MDS dated 02/26/26 documented an existing Stage III pressure ulcer and the need for pressure-reducing devices and pressure ulcer care, yet the care plan dated the same day did not include any problem, goal, or interventions related to this Stage III ulcer. The Nursing Admission/Readmission Data Collection Assessment dated 02/27/26 documented no impaired skin integrity and no open areas, despite a hospital post-acute handoff dated 02/22/26 indicating a pressure ulcer to the midline sacral spine. The medical record contained no documented admission skin assessment. Subsequent nursing documentation for Resident #3 showed further failures in assessment, measurement, and timely intervention. Progress notes on 03/06/26 and 03/07/26 recorded “excoriation” to the buttocks but did not include wound measurements, descriptive characteristics, or documentation of physician and family notification. A wound assessment dated 03/09/26 at 3:01 p.m. identified a facility-acquired Stage III pressure ulcer on the coccyx with 50% slough, serosanguinous drainage, and specific measurements, and noted that the family and physician were notified; this was the first documented wound assessment after admission. Although the assessment indicated the care plan was reviewed and updated, the care plan did not reflect the identified Stage III pressure ulcer at that time. Physician orders for weekly skin assessments, a low air loss mattress, and wound treatment were entered beginning 03/09/26 and 03/12/26, but the TAR showed wound treatment was not initiated until 03/12/26. There was no further wound documentation until a 03/15/26 progress note describing moderate purulent drainage with odor, and a 03/17/26 skin assessment documented a larger Stage III coccyx ulcer with increased slough and new orders for Santyl. CNA and LPN interviews indicated the wound was noticed around 03/09/26 with slough and green drainage, that no admission or weekly skin assessments had been completed, and that the wound was likely present on admission but could not be proven due to missing assessments. For Resident #4, the facility also failed to assess, document, and care plan for skin breakdown and pressure ulcer risk. The care plan dated 12/22/25 contained no problem or interventions related to risk for skin breakdown or existing skin breakdown, despite an admission MDS indicating severe cognitive impairment, risk for pressure ulcers, and the need for pressure-reducing devices. A physician order dated 02/02/26 directed barrier cream to the coccyx/peri-area every shift for prevention, and the Nursing Admission/Readmission Data Collection Assessment dated 02/15/26 documented no impaired skin integrity. However, a bath assessment dated 02/16/26 noted “bumps” on the resident’s bottom, and the charge nurse did not sign this form. The resident was later hospitalized, and a 02/21/26 progress note recorded that a family member reported the hospital had found two bed sores on the resident’s backside with a current MRSA infection. When the resident returned from the hospital on 02/28/26, a progress note documented shearing to bilateral buttocks with blanchable erythema, but there was no documented wound assessment, no new wound care orders, and no physician or family notifications related to these findings. From 02/28/26 through 03/05/26, the record contained no skin assessments, no wound-related progress notes, no new wound care orders, and no updates to the care plan regarding skin breakdown or risk, despite staff interviews indicating that wounds on the resident’s bottom had been present up to about two months earlier and that staff had been applying ointment. Interviews with staff and leadership further demonstrated systemic failures in implementing the facility’s skin integrity policy and monitoring processes. A CNA reported not being aware of nurses completing wound monitoring rounds since the new DON was hired, did not believe nurses were completing skin assessments timely, and had not seen nurses measure wounds, though they occasionally asked for assistance with repositioning during wound care. A CMT stated that if a new or worsening open area was observed, it should be reported to the charge nurse for assessment, documentation, and physician/family notification, but records did not show this occurring consistently. An LPN stated that skin assessments and wound measurements should be completed weekly and that new open areas should trigger assessment, measurement, documentation, and notifications, yet he was not aware of anyone completing weekly wound rounds. The DON acknowledged that admission and weekly skin assessments were expected, that responsibility for wound and skin assessments had shifted from a former ADON to charge nurses, that she did not fully understand the electronic system or how nurses were cued to complete assessments, and that she had not audited skin assessments. She also stated that weekly wound monitoring and measuring became her responsibility after the ADON left and that she did not complete them until the end of the week because she was unaware of all required steps. The Administrator and MDS Coordinator both described expectations that new open areas be immediately assessed, measured, documented, and care planned, with prompt physician notification and implementation of prevention measures, but the documented care for Residents #3 and #4 did not meet these stated expectations.
Failure to Implement and Communicate Food Allergy Information Resulting in Allergic Reaction
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s known food allergies were fully assessed, documented, care planned, and incorporated into diet orders and dietary service processes, resulting in the resident being served a food to which they were allergic. The facility’s own policy required assessment of food allergies upon admission, documentation of all reported allergies in the medical record, notation of severe allergies on the resident profile, and communication of these allergies to the dietitian and food and nutrition services. For this resident, the face sheet listed allergies to beef, beef-derived products, grapes, peanuts, wheat, and Mountain Dew, and the Nursing Admission Data Collection listed allergies to beef-derived products, peanuts, and wheat. However, the admission assessment did not indicate any special nutritional needs, and the comprehensive care plan created on admission did not include any problem, goal, or intervention related to diet or known food allergies. The resident’s Physician Order Sheet for the admission month contained an order for a regular diet with regular texture and consistency, but it did not address or restrict any of the resident’s documented food allergies. The DON later stated she had entered the allergies into the allergies tab of the electronic medical record but did not add them to the diet order. Staff interviews showed that multiple disciplines relied on diet orders and dietary cards to identify allergies, yet the diet order itself lacked allergy information. The Interdepartmental Notification of Diet policy required written notice of diet orders and changes to food and nutrition services, but in this case, the process was inconsistently followed: staff described both prior use of diet slips and a current expectation of verbal communication with the Kitchen Manager, and there was no clear, single, accurate diet communication tool in place for this resident. On the day of the incident, the resident, who was cognitively impaired and required supervision for eating, was served a beef taco at lunch. The Kitchen Manager acknowledged he was aware the resident had allergies but stated the diet order did not indicate them and that two dietary cards had been created for the resident—one listing allergies and one without allergies—and the wrong card was used when preparing the tray. A CNA and a CMT both reported seeing two different dietary cards for the resident, one with the correct room number but no allergies and another with allergies but the wrong room number. The CMT observed the resident eating a beef taco and was not aware of any allergies at that time. Later that day, the resident developed vomiting and diarrhea, became unresponsive on the toilet, and was transferred to the hospital. Hospital documentation indicated the resident was admitted for an allergy to beef with a delayed reaction after eating a beef taco at the facility, and the resident received treatment including Benadryl, Solu-Medrol, and Pepcid. Only after the hospital transfer was a care plan created that specifically addressed the resident’s allergies.
Failure to Account for and Properly Document Destruction of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of property when staff could not account for two residents' controlled medication cards containing narcotics that were in the facility's possession. The missing medications were oxycodone/acetaminophen tablets, each card containing 30 tablets, prescribed for pain management. Documentation showed that the medication cards were marked as destroyed on narcotic count sheets, but there was no evidence or witness to the destruction, and the destruction log binder did not contain the required destruction sheets for these medications. Interviews and record reviews revealed that the former DON and a Certified Medication Technician (CMT) signed off on the destruction of the medications, despite both stating they did not actually destroy the medications. The CMT reported being asked by the former DON to sign the narcotic sheet, with the understanding that the matter was taken care of, but did not witness or participate in the destruction. The former DON admitted to incorrectly marking the medications as destroyed on the narcotic sheets, stating she was not trained as a DON and believed it would be wrong to write 'missing' or 'stolen.' Multiple staff interviews confirmed that the medications were not destroyed and that the required procedures for handling, counting, and documenting controlled substances were not followed. Both residents involved had documented needs for pain management and were receiving scheduled opioid medications for chronic pain conditions. The facility's policies required strict procedures for the handling, counting, and destruction of controlled substances, including dual signatures and proper documentation, none of which were followed in these cases. The failure to account for the controlled medications and the improper documentation constituted misappropriation of resident property.
Failure to Timely Report Missing Narcotics as Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of misappropriation of property, specifically missing narcotics for two residents, were reported to the State Survey Agency within the required 24-hour timeframe. On a Sunday, an agency LPN notified the DON about potentially missing or misplaced narcotics. The DON then informed the Administrator, and both met at the facility to investigate the issue. Despite the facility's policy requiring prompt reporting of suspected misappropriation, the DON did not report the incident to the state or the regional team as initially claimed. The missing medications, identified as oxycodone/APAP tablets belonging to two residents, were not located, although all residents continued to receive their pain medications as ordered. Interviews with staff, including RNs, CMTs, and administrative personnel, revealed a general understanding that missing narcotics should be reported to the DON and to the state agency within a short timeframe, ranging from two to four hours. However, the DON and Administrator decided not to report the incident immediately, believing it was not a two-hour reportable event since it did not involve abuse. The misappropriation was ultimately reported to the state several days after the initial discovery, contrary to facility policy and regulatory requirements.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program, as evidenced by the lack of appropriate signage and personal protective equipment (PPE) usage for residents under enhanced barrier precautions (EBP). Specifically, for one resident with an indwelling medical device, staff did not post EBP signage or wear gowns and gloves as required by the Centers for Disease Control (CDC) guidelines. Observations revealed that Certified Nurse Aides (CNAs) entered the resident's room without the necessary PPE and failed to perform hand hygiene before and after resident care activities. Additionally, the facility's staff did not adhere to standard hand hygiene practices during perineal care for three residents. CNAs were observed not washing or sanitizing their hands before putting on gloves, after removing soiled gloves, or when moving between contaminated and clean tasks. This non-compliance with hand hygiene protocols was noted during the care of residents who were incontinent of bowel and bladder, increasing the risk of infection transmission. Interviews with staff, including CNAs, Licensed Practical Nurses (LPNs), and the Director of Nursing (DON), revealed a lack of awareness and understanding of the EBP requirements and hand hygiene protocols. Some staff members were unaware of the EBP policy, while others incorrectly believed that gowns were only necessary if visible in the room. The facility's failure to ensure proper training and adherence to infection control measures contributed to the deficiencies observed during the survey.
Failure to Protect Resident from Mental Abuse by Staff
Penalty
Summary
The facility failed to ensure that a non-verbal resident, who is dependent on staff for all personal needs and mobility, was free from mental abuse by staff. Certified Nurse Aide (CNA) S made comments to the resident intended to upset him/her, which resulted in the resident becoming visibly upset, red-faced, teary-eyed, and grunting. The resident's response to the CNA's presence and comments was documented by multiple staff members, who reported the resident's distress and the inappropriate comments made by CNA S, including statements about hoping the resident would dream of certain people, which were perceived as derogatory and abusive. Several staff members, including CNAs and nurses, witnessed or were informed about the abusive comments made by CNA S. Despite the resident's non-verbal status, his/her reactions, such as grunting, pointing, and becoming visibly upset, indicated distress and fear when encountering CNA S. The staff members reported these incidents to their supervisors, but there was a lack of proper documentation and immediate action taken to address the abuse. The facility's failure to document the incidents and investigate the allegations promptly contributed to the deficiency. The resident's care plan highlighted his/her communication difficulties and the need for staff to use specific techniques to interact effectively with him/her. However, the actions of CNA S, as reported by other staff members, directly contradicted these guidelines and resulted in mental abuse. The facility's administration, including the former Director of Nursing (DON) and Administrator, were informed of the incidents but did not take adequate steps to investigate or address the abuse, leading to a finding of immediate jeopardy by the surveyors.
Significant Medication Error Due to Misinterpretation of Physician Orders
Penalty
Summary
The facility failed to ensure that residents remained free from significant medication errors when staff administered a fentanyl patch and hydrocodone-APAP to a resident without orders. This resulted in significant side effects and hospitalization for the resident. The error occurred because the physician wrote orders for multiple residents on the same piece of paper, and the nurse misread the orders, administering medications intended for another resident to the affected resident. The resident experienced seizures, high blood pressure, and low blood oxygen levels, necessitating emergency medical intervention and hospitalization. The resident, who had diagnoses including a mini-stroke, unspecified dementia, and high blood pressure, was admitted to the facility without orders for pain medications. However, the nurse administered a fentanyl patch and hydrocodone-APAP based on a misinterpretation of the physician's handwritten orders. The nurse did not document the administration of these medications in the resident's medical record. Later that day, the resident exhibited signs of a possible seizure, high blood pressure, and low blood oxygen levels, leading to the administration of lorazepam and emergency transport to the hospital. Interviews with staff revealed that the physician's practice of writing orders for multiple residents on the same piece of paper without clear separation between orders contributed to the error. The nurse did not verify the orders against the resident's Medication Administration Record (MAR) or Physician Order Sheet (POS) before administering the medications. The facility's policies on medication administration and monitoring were not followed, leading to the significant medication error and subsequent adverse effects on the resident.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. The facility's job description for the DON outlines extensive responsibilities, including planning, organizing, and directing the nursing service department to ensure high-quality care. Despite these requirements, the facility has been without a DON since February 2024, as confirmed by multiple staff members and the Regional Director of Clinical. The former DON left without notice, and attempts to fill the position have been unsuccessful, with scheduled interviews not resulting in any hires. Interviews with various staff members, including the Administrator, RNs, and the MDS/Care Plan Coordinator, revealed that the absence of a DON has left the facility without proper oversight and guidance for the nursing staff. The Assistant Director of Nursing (ADON) and Regional Corporate Clinical have been filling in, but the lack of a designated DON has impacted the facility's ability to maintain continuity of care and fulfill the administrative and clinical responsibilities outlined in the DON's job description.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a manner that protects it from potential contamination. Observations revealed multiple instances of food items in the reach-in and walk-in refrigerators that were not labeled or dated, including individual servings of peach pie, cheese sandwiches, cottage cheese, and various condiment containers. Additionally, some fruits were found wilted and brown. Interviews with dietary staff and the Dietary Manager confirmed that the responsibility for labeling and dating food items was not consistently followed, despite the facility's policy requiring it. The Administrator also acknowledged that food should be labeled and dated before being stored in the refrigerator. The facility did not maintain non-food contact surfaces in a clean and debris-free condition. Observations showed peeling paint on the ceiling above the three-vat sink and food prep table, and areas of the kitchen floor that were rough, porous, and missing tiles, which could trap food and dirt. Interviews with dietary aides and the Dietary Manager indicated that the kitchen floor was not cleanable with a mop and that maintenance issues were to be reported to the maintenance supervisor. The Administrator confirmed that the Dietary Manager is responsible for the kitchen's condition and that maintenance issues should be reported. The facility failed to sanitize dishes in the three-vat sink according to the manufacturer's requirements. Observations showed that Cook L washed and rinsed pots and pans but did not use the sanitizer sink due to the absence of a plug. Interviews with dietary staff and the Dietary Manager revealed that the three-vat sink was intended for washing, rinsing, and sanitizing, but the lack of a plug prevented proper sanitization. The Dietary Manager was unaware of the need for a plug and confirmed that all pots and pans should be sanitized. The Administrator stated that staff should use the three-vat sink for washing, rinsing, and sanitizing pots and pans used in food preparation.
Failure to Review and Update Facility Assessment Annually
Penalty
Summary
The facility failed to review and update the comprehensive facility assessment annually, as required by Federal regulations. The last documented review of the facility assessment was completed in 2020, and no subsequent reviews have been conducted since then. The new Administrator, who started on 04/05/24, acknowledged that the facility assessment should be reviewed yearly to determine resident acuity needs and required staffing. Both the Administrator and the Regional Corporate Clinical Staff confirmed that the facility assessment had not been reviewed since 2020. This oversight could delay the services needed to care for the residents in day-to-day operations and emergencies, affecting all facility occupants. The facility census was 60 at the time of the survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program by not adhering to its policy for monitoring and preventing the development of Legionella bacteria in the water system. Observations revealed numerous empty resident rooms and a full hall with no residents assigned, which were not being regularly flushed as required. Interviews with the head of Environmental Services and the Maintenance Director confirmed that there was no schedule or documentation for flushing sinks, showers, or toilets, and no water management team meetings were being held as stipulated by the facility's policy. The Administrator, who was new to the facility, was also unaware of any water management or Legionella prevention policies. The facility also failed to update policies, educate staff, and implement Enhanced Barrier Precautions (EBP) for residents with wounds, catheters, or other indwelling medical devices. The facility's infection control policies did not address the use of gowns and gloves during high-contact resident care activities. Observations showed that staff did not wear gowns when assisting residents with catheters or wounds, and there was no PPE available immediately outside resident rooms. Interviews with various staff members, including CNAs, RNs, and the ADON, revealed a lack of awareness and training regarding EBP. Specific residents were identified as being affected by these deficiencies. Resident #110 had a PICC line for antibiotics, Resident #47 had a PICC line, Resident #160 had an indwelling Foley catheter, Resident #20 had an indwelling Foley catheter, Resident #161 had pressure ulcers, and Resident #25 had wounds. Observations and interviews confirmed that staff did not follow EBP protocols when providing care to these residents, further highlighting the facility's failure to implement necessary infection control measures.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective and complete antibiotic stewardship program by not maintaining a current and ongoing antibiotic log of residents with active infections. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide an antibiotic log and failed to track residents on antibiotics for various infections. The facility's policy required an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program to monitor antibiotic use, but this was not effectively executed. The Assistant Director of Nursing (ADON), who also served as the Infection Preventionist (IP), admitted to not maintaining a resident-specific log or evaluating the information collected. The ADON had been in the position since December 2023 and had primarily been working on the floor rather than focusing on the IPCP responsibilities. The ADON used a map with colored markings to track infections but did not maintain a detailed log or conduct evaluations. The previous Director of Nursing (DON) and/or Administrator were reportedly responsible for monitoring antibiotic stewardship, but this was not effectively transitioned to the current ADON/IP. The facility's provided list of residents on antibiotics showed multiple residents receiving various antibiotics for infections such as urinary tract infections (UTIs). However, there was no comprehensive log or evaluation of antibiotic use trends. The ADON/IP was unsure if any staff audited charts, and the Infection Surveillance binder only contained maps without detailed logs. Interviews with the Administrator and Corporate Nurse confirmed that the IP should be responsible for keeping a log of all antibiotics prescribed to residents to monitor infection trends, which was not being done.
Failure to Maintain Comfortable Temperature Range
Penalty
Summary
The facility failed to maintain a comfortable temperature range of 71 to 81 degrees Fahrenheit in resident rooms and common areas, affecting ten residents out of a sample of 26. Observations and interviews revealed that temperatures in various parts of the facility ranged from 78 to 84 degrees Fahrenheit, which was uncomfortable for the residents. Several residents, including those with multiple sclerosis, chronic obstructive pulmonary disease, congestive heart failure, and other conditions, reported feeling too hot, which exacerbated their symptoms and caused discomfort. For instance, one resident with multiple sclerosis mentioned that the heat worsened their symptoms, while another with COPD and congestive heart failure requested a fan due to the warmth in their room. The facility did not have a policy regarding the heating and cooling system or monitoring of facility temperature for resident comfort. The facility's heating and cooling system was described as a boiler and chiller system that could only be either on or off, with a usual switch from heat to air conditioning occurring around mid-April. The Maintenance Director was unaware of the residents' complaints about the heat until the survey and mentioned that the facility would provide fans and open windows if it was too hot. However, there was no regular monitoring of the facility or resident room temperatures unless someone complained. Staff interviews indicated that the unit was consistently warm, and residents had complained about the temperature. Some staff members mentioned that they would open windows or provide fans to alleviate the heat. During interviews, the Assistant Director of Nursing and the Administrator acknowledged that staff should monitor building temperatures and adjust thermostats, open windows, or provide fans if residents complained of being too hot or too cold. However, there was no formal policy in place for monitoring temperatures. The Administrator stated that the Maintenance Director was responsible for monitoring temperatures, but ultimately, it was the Administrator's responsibility. The lack of a formal policy and regular monitoring led to the deficiency in maintaining a comfortable environment for the residents.
Failure to Conduct Required Background Checks Before Employee Contact with Residents
Penalty
Summary
The facility failed to follow their abuse prevention policy by not requesting a Criminal Background Check (CBC) or Family Care Safety Register (FCSR) check prior to a Licensed Practical Nurse (LPN) having contact with residents. Specifically, LPN D was hired on 12/20/22 and started working on 01/06/23 without the required CBC or FCSR inquiry being completed. The FCSR inquiry for LPN D was not completed until 08/25/23, well after the LPN had already been in contact with residents. This oversight was identified during a review of a sample of 10 hired employees in a facility with a census of 60 residents. Interviews with the payroll/human resource (HR) staff and the Administrator confirmed that the hiring process should include an FCSR/CBC inquiry for all employees and that no employee should have contact with residents until these checks are completed. The failure to conduct the required background checks before allowing LPN D to interact with residents is a clear violation of the facility's abuse prevention policy, which mandates screening to prevent the employment of individuals with a history of abuse, neglect, or mistreatment of residents.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to deficiencies in their care. For Resident #2, the care plan did not include the use of oxygen or the care of oxygen equipment, despite the resident having orders for oxygen therapy due to congestive heart failure. This omission was confirmed through interviews with multiple staff members, including CNAs, CMTs, RNs, the Social Service Director, the Assistant Director of Nursing, the MDS Coordinator, and the Administrator, all of whom acknowledged that oxygen use should be included in the care plan. For Resident #160, the facility failed to update the care plan to reflect the resident's use of a vape during smoke breaks. Initially assessed as a non-smoker, the resident's care plan did not include any information about smoking safety or supervision during smoke breaks. This discrepancy was observed during multiple instances when the resident was seen using a vape, and staff confirmed that the care plan should have been updated to include this information. Resident #259's care plan did not address impaired skin integrity or related interventions, despite the resident having multiple orders for wound care. The resident's care plan was only revised to include wound care on 04/12/24, even though the resident had been receiving treatment for skin conditions since March 2024. Interviews with various staff members, including CMTs, RNs, the ADON, the MDS Coordinator, and the SSD, confirmed that wound care should have been included in the care plan from the beginning.
Failure to Care Plan and Document Side Rail Use
Penalty
Summary
The facility failed to care plan the use of side rails and obtain informed consent for their use for two residents, and did not complete gap measurements for installed side rails for three residents. The facility's policy on the proper use of side rails, revised in December 2016, outlines the need for assessments, informed consent, and proper documentation, none of which were followed for the residents in question. Specifically, Resident #6 and Resident #12 had side rails installed without documented assessments, gap measurements, or informed consent. Resident #23 had consent documented but lacked gap measurements and assessments for side rail use. Observations and interviews revealed that Resident #6 had severe cognitive impairment and required assistance for bed mobility and transfers. Despite this, the resident's care plan did not address the use of side rails, and no assessments or measurements were documented. Similarly, Resident #12, who also had severe cognitive impairment and was dependent on staff for bed mobility and transfers, had side rails installed without proper documentation or assessments. Resident #23, with moderate cognitive impairment and dependent on staff for bed mobility and transfers, had consent for side rail use but lacked documented gap measurements and assessments. Interviews with facility staff, including the Restorative Nursing Aide, Certified Nursing Assistant, Certified Medical Technician, Maintenance Supervisor, and Therapy Director, indicated a lack of clarity and responsibility regarding the assessment, installation, and maintenance of side rails. The staff were unsure who was responsible for completing the necessary assessments, obtaining consent, and ensuring the side rails met safety requirements. The Administrator confirmed that side rail assessments, evaluations for positioning, family permission, and measurements for appropriate fit should be completed and documented in the care plan, but these steps were not followed for the residents in question.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to ensure food was prepared in a form to meet residents' needs when staff did not prepare pureed food to the proper consistency for one resident on a pureed texture diet. Resident #26, who had severe cognitive impairment and was on a pureed diet as per physician's order, received a dessert that was not prepared according to the facility's policy. The dietary aide used apple juice instead of milk to puree cherry crisp, resulting in a consistency that was too thin and drinkable through a straw. This inconsistency was observed during lunch, where the resident had difficulty consuming the dessert due to its runny texture. Interviews with the dietary aide, dietary manager, and other staff revealed that the dietary aide did not follow the recipe and was instructed by the dietary manager to use apple juice instead of milk. The dietary manager believed that apple juice would mix better with the cherry crisp. The facility's policy stated that pureed food should not be thinner than pudding or thicker than mashed potatoes, which was not adhered to in this instance. The administrator and registered dietician confirmed that staff should follow recipes and ensure the correct consistency of pureed foods to meet residents' nutritional needs.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to notify two residents and/or their representatives in writing of a transfer or discharge to a hospital, including the reasons for the transfer. For Resident #160, who was admitted with multiple sclerosis, staff documented seizure-like activity and severe muscle rigidity, leading to a transfer to the emergency room. However, there was no documentation of a written notice of transfer provided to the resident or their representative. Similarly, Resident #21, who had multiple diagnoses including hemiplegia, congestive heart failure, chronic kidney disease, schizoaffective disorder, and dementia, experienced sharp chest pain and was transferred to the emergency room. Again, there was no documentation of a written notice of transfer provided to the resident or their representative. Interviews with various staff members, including registered nurses, the Assistant Director of Nursing, and Social Services, revealed that while pertinent medical information was sent with the residents to the hospital, written notices of transfer were not provided to the residents or their representatives. The Social Services staff mentioned that a notice is sent to the ombudsman at the end of every month, but not to the families or resident representatives. The Administrator confirmed that staff should send a transfer letter when sending a resident to the hospital, indicating a lapse in the facility's protocol for notifying residents and their representatives in writing about transfers or discharges.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility failed to provide information to the resident and/or resident's representative regarding the bed hold policy when two residents were transferred to the hospital. The facility's policy, dated February 2014, requires that the bed hold agreement be obtained for each occurrence of hospital or therapeutic leave. However, the review of the medical records for Resident #160 and Resident #21 showed that staff did not document providing notice of a bed hold agreement at the time of transfer. Resident #160, who has multiple sclerosis, was transferred to the emergency room due to severe muscle rigidity and uncontrollable tremors. Similarly, Resident #21, who has multiple diagnoses including hemiplegia, CHF, CKD, schizoaffective disorder, and dementia, was transferred to the emergency room due to sharp chest pain. In both cases, there was no documentation of the bed hold agreement being provided to the residents or their representatives. Interviews with various staff members, including RNs, the Assistant Director of Nursing, and Social Services, revealed that the facility had not been sending bed hold notices to residents or their families. RN F mentioned that they notify the family by phone of the hospital transfer but do not send a bed hold notice. RN E stated that the facility had stopped sending bed hold policies about a year ago, and the reason for this was unknown. The Assistant Director of Nursing and Social Services both confirmed that they had not been sending bed hold notices. The Administrator and Corporate Nurse acknowledged that staff should send a bed hold notice when transferring a resident to the hospital.
Failure to Ensure Proper Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure that all dialysis residents received services consistent with professional standards of practice. Specifically, the staff did not routinely communicate and collaborate with the dialysis center after appointments for one resident. The facility's policy required the use of a dialysis communication form to facilitate the sharing of resident information between the facility and the dialysis center. However, the nursing staff did not consistently send or receive these forms, nor did they follow up with the dialysis center when the forms were not returned with the resident. This lack of communication was observed for multiple dates over a period from February to April, during which the resident attended dialysis appointments without the necessary documentation being completed or reviewed by the facility staff. The resident in question had diagnoses including end-stage renal disease (ESRD) and diabetes, requiring hemodialysis three times a week. Despite changes in the resident's dialysis schedule, the facility staff did not update the physician orders or the resident's care plan to reflect the new appointment days. Interviews with various staff members, including the MDS/Care Plan Coordinator, RN, ADON, and the Administrator, revealed that the staff were aware of the policy but failed to adhere to it. The staff did not consistently send the communication form with the resident, did not ensure its return, and did not document any follow-up communication with the dialysis center, leading to a significant lapse in the continuity of care for the resident.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that all residents received necessary behavioral health care and services, specifically for one resident who exhibited signs and symptoms of depression. The resident, who had diagnoses including COPD, CHF, and was receiving palliative care, showed signs of depression during a preadmission hospice visit and was prescribed sertraline. Despite this, the facility did not care plan for the resident's depression or antidepressant use, and social services did not follow up with the resident regarding their depression. The resident's medical record also lacked documentation of activity attendance, and the resident expressed feelings of sadness and a desire to talk to someone about their feelings during an interview and observation session. Staff interviews revealed a lack of communication and follow-up regarding the resident's depression symptoms, with social services and nursing staff not adequately addressing the resident's needs or notifying the physician as required. The resident's quarterly MDS indicated mild depression, with symptoms such as feeling down, trouble sleeping, and feeling tired nearly every day. The social services assessment also highlighted the resident's significant loss due to not living in their own home and the need for emotional support. However, the care plan only mentioned hospice services related to COPD and did not address the resident's depression or the need for psychosocial support. Interviews with staff, including RNs, the MDS Coordinator, and the Assistant Director of Nursing, revealed inconsistencies in the process of identifying and addressing depression, with some staff unaware of the resident's depression screening results and others not following up appropriately. The facility's failure to provide a behavioral health policy and the lack of documented follow-up by social services contributed to the deficiency. The resident's expressed need for emotional support and the staff's inconsistent responses to signs of depression highlight the facility's failure to ensure the highest practical psychosocial well-being for the resident. The Administrator confirmed that the social worker is responsible for mood and behavior assessments and should share information with department heads and nursing staff, but this process was not effectively implemented in this case.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days, as required by regulations. Specifically, Resident #9 had an ongoing PRN order for alprazolam, a psychotropic medication used to treat anxiety disorders, without a physician review and justification beyond the initial 14-day period. The resident, who was cognitively intact and diagnosed with anxiety and major depressive disorder, had an order for alprazolam 0.25 mg to be taken every six hours as needed. The medication was administered three times in February 2024, but there was no documentation of a re-evaluation or justification to continue the order beyond the original 14 days. Interviews with facility staff, including a registered nurse, the assistant director of nursing, and the medical director, revealed a lack of awareness and oversight regarding the 14-day limit for PRN psychotropic medications. The facility's policy on psychotropic medication use did not address the requirements for PRN orders, contributing to the oversight. The assistant director of nursing and the medical director both indicated that the pharmacy typically monitors medications and sends recommendations for discontinuation or dosage adjustments. However, in this case, the pharmacy review process failed to identify the need to re-evaluate or discontinue the PRN order for alprazolam. The administrator confirmed that PRN psychotropic medications should have an end date of 14 days, but this protocol was not followed for Resident #9, resulting in a deficiency in medication management and regulatory compliance.
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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