Aspire Senior Living Oak Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Grove, Missouri.
- Location
- 2108 Sw Mitchell Street, Oak Grove, Missouri 64075
- CMS Provider Number
- 265710
- Inspections on file
- 17
- Latest survey
- February 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspire Senior Living Oak Grove during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was physically abused by a cognitively intact roommate, who admitted to striking the resident in response to nighttime noises. The incident resulted in a black eye, dried blood, and bite marks, and was confirmed through staff observations, resident interviews, and facility investigation as resident-to-resident abuse.
The facility did not provide written notification to the DPOA for two cognitively impaired residents when one was moved to a secured care unit and the other received a new roommate. Instead, staff relied on verbal communication and did not document or issue written notices as required by policy, leaving the DPOA uninformed about changes except on one occasion.
The facility failed to ensure that the arbitration agreement was optional and clearly communicated to residents and their representatives. Two residents were affected, with one being cognitively intact and unable to recall being informed about the option to rescind the agreement, and another's representative unsure about the rescission period. The Social Services Director assumed understanding if no questions were asked, and the facility has since updated its admission packet to exclude the arbitration agreement.
A facility failed to offer a resident the opportunity to formulate advanced directives, specifically to designate a family member as their Durable Power of Attorney (DPOA) for health care decisions. The resident was alert and oriented upon admission, but the Social Service Director (SSD) did not inquire about establishing an advanced directive, contrary to facility policy. The Director of Nursing (DON) confirmed that the SSD was responsible for this task, which should occur during admission and care plan meetings.
The facility failed to provide timely and complete SNF ABN notices to three residents when their Medicare Part A coverage was expected to end. Residents were not informed of the per diem rate of services as soon as reasonably possible when the NOMNC was issued. The Social Services Director did not include estimated costs on the ABN forms, and the Administrator confirmed that this information should be shared by the Business Office Manager during clinical meetings.
A resident with severe cognitive impairment accessed and ingested medications from an unlocked cart, leading to hospitalization. The resident, who had high blood pressure, dementia, and depression, was found with medication cards and admitted to consuming two pills. The facility's policy requires medications to be stored securely, but the cart was left unlocked, allowing the resident to access the medications.
A resident with respiratory issues did not receive proper BiPAP therapy due to the facility's failure to obtain necessary physician orders and adhere to equipment maintenance protocols. The BiPAP machine was improperly stored, and staff did not follow guidelines for documenting and managing the resident's respiratory care.
A resident with broken and jagged teeth did not receive necessary dental services despite having a physician's order to see a dentist as needed. The resident, who was cognitively intact, had not seen a dentist since admission, and their dental care was not addressed in their care plan. Facility staff were unaware of the resident's dental needs, and there was no system in place to ensure routine dental visits.
The facility failed to protect a resident from abuse when another resident with known aggressive behavior physically assaulted them on two separate occasions. Despite the aggressor's history of mental health issues and verbal aggression, the facility did not increase oversight or implement additional measures to prevent further incidents.
The facility failed to provide an appropriate involuntary transfer discharge for a resident with Schizoaffective Disorder, Dementia, and Anxiety Disorder. The resident was transferred to the hospital and not allowed to return, without proper documentation, physician orders, or a 30-day notice and appeal process, as required by the facility's policy.
The facility failed to ensure the PASARR Level I and, if indicated, Level II was obtained for a resident with Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder. The resident's electronic medical record showed no PASARR, and the Social Service Director admitted to not following up on the request from the prior facility. The Administrator was unaware of the missing PASARR, despite the resident exhibiting moderate cognitive impairment and behavioral issues.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Parkinson's disease, dementia, and anxiety was physically abused by a cognitively intact roommate who also had a history of neurological and behavioral conditions. The incident took place during the early morning hours, when staff observed the aggressor sitting by the victim's bed. The aggressor admitted to striking the other resident in response to noises made during the night, stating that he had asked the resident to stop and ultimately slapped him on the face. The victim sustained a black eye, dried blood around the mouth, and bite marks on the tongue as a result of the altercation. Staff interviews and written statements revealed that the door to the shared room was often kept closed due to noise from the hallway, and that staff had checked on both residents during the night. At approximately 3:15 A.M., a staff member found the aggressor by the victim's bed and was told he was trying to get the other resident to stop moving around. The staff member checked on the victim, who appeared tired but had no visible injuries at that time. Later, around 4:30 A.M., staff noticed bruising and blood on the victim's face, at which point the victim indicated that the roommate had hit him. The facility's investigation confirmed that an altercation had occurred, resulting in injury to the resident with severe cognitive impairment. The aggressor admitted to staff and during interviews that he had struck the other resident due to frustration with the noises made during the night. Staff and leadership interviews indicated that the incident was not anticipated, as the aggressor had no prior history of such behavior. The event was classified as resident-to-resident abuse, and the facility's abuse prevention policy defined such actions as the willful infliction of injury or harm.
Failure to Provide Written Notification of Room and Roommate Changes
Penalty
Summary
The facility failed to provide written notification to the Durable Power of Attorney (DPOA) for two residents regarding changes in room and roommate assignments, as required by both facility policy and federal regulations. Both residents were cognitively impaired, with one being moderately impaired due to depression, heart disease, and anxiety, and the other severely impaired with dementia and Alzheimer's disease. The DPOA had been invoked for both residents due to their incapacity. Despite this, when one resident was moved to a secured care unit due to wandering and elopement risk, and the other was assigned a new roommate, the facility only provided verbal notification to families and did not document or issue written notices as required. Interviews with facility staff, including the Social Services Designee, Administrator, and DON, confirmed that notifications regarding room and roommate changes were made verbally and not in writing. The DPOA for one of the residents reported not being informed about roommate changes except on one occasion and was not given a choice regarding new roommates. Facility policy explicitly requires written notification to residents and their representatives for such changes, but this was not followed or documented in these cases.
Failure to Provide Optional Arbitration Agreement
Penalty
Summary
The facility failed to provide a binding arbitration agreement that was optional and clearly communicated to residents and their representatives. The arbitration agreement was part of the admission packet and required residents to engage in mandatory non-binding mediation and arbitration before pursuing other remedies. However, the agreement did not inform residents or their representatives that signing was not a condition of admission and that they could rescind the agreement within 30 days. This affected two residents, one of whom was cognitively intact and could not recall being informed about the option to rescind the agreement, and another whose representative was unsure if they were informed about the rescission period or the non-mandatory nature of the agreement. Interviews with facility staff revealed that the Social Services Director (SSD) was responsible for ensuring residents understood the admission packet, but did not go over the arbitration agreement in detail, assuming understanding if no questions were asked. The SSD could not recall if the agreement mentioned the rescission period. The facility had since updated its admission packet to exclude the arbitration agreement, but agreements signed before this update remained in effect. The Administrator acknowledged that the agreement should have allowed for rescission and should not have been mandatory, while the Director of Operations noted that the outdated agreement was a result of using the previous company's admission packet after a change of ownership.
Failure to Offer Advanced Directive Formulation
Penalty
Summary
The facility failed to offer a resident the opportunity to formulate advanced directives, specifically to identify a family member as their Durable Power of Attorney (DPOA) for health care decisions. This deficiency was identified during an interview and record review, where it was noted that the resident was alert and oriented upon admission and had expressed a desire to have their family member designated as their DPOA. Despite this, the Social Service Director (SSD) did not inquire if the resident wanted to establish an advanced directive at the time of admission, nor was it reviewed annually as required by the facility's policy. The facility's policy mandates that residents be given the option to complete a DPOA for Health Care upon admission if they have not already done so. However, the SSD admitted to not being aware of this requirement and stated that they typically waited for residents or their families to approach them about formulating an advanced directive. The Director of Nursing (DON) confirmed that the SSD was responsible for offering to formulate advanced directives and that this should occur during admission and care plan meetings. This oversight resulted in the resident's wishes not being documented or honored as per the facility's policy.
Failure to Provide Timely and Complete SNF ABN Notices
Penalty
Summary
The facility failed to provide timely and complete Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) to three residents when their Medicare Part A coverage was expected to end. Residents were not informed in writing of the per diem rate of services as soon as reasonably possible when the Notice of Medicare Non-Coverage (NOMNC) was issued. Specifically, Resident #537 received the NOMNC indicating the end of Medicare Part A skilled services on 5/6/24, but the SNF ABN was not provided until the same day, lacking the estimated cost for continued services. Similarly, Resident #64 received the NOMNC on 5/23/24, but the SNF ABN was delayed until 5/28/24, also missing the cost estimate. Resident #43 received both the NOMNC and SNF ABN on 1/28/24, but the SNF ABN did not include the estimated cost. Interviews revealed that the Social Services Director (SSD) was responsible for issuing the SNF ABN and ensuring it contained all required information, including the estimated costs for continued services. However, the SSD admitted to not including these costs on the ABN forms. The Administrator confirmed that the cost per day should be included on the ABN form and that the Business Office Manager (BOM) shares this information during morning clinical meetings. The SSD was expected to issue the SNF ABN concurrently with the NOMNC, but this procedure was not followed, leading to the deficiency.
Medication Cart Security Breach Leads to Resident Ingesting Unprescribed Medications
Penalty
Summary
The facility failed to ensure that medication carts were locked at all times when not in use, leading to a resident with severe cognitive impairment accessing and ingesting medications from an unlocked cart. The resident, who had diagnoses of high blood pressure, dementia, and depression, was found with medication cards in their wheelchair and admitted to consuming two pills. This incident occurred despite the facility's policy requiring all medications to be stored securely in locked cabinets or carts. On the morning of the incident, a registered nurse discovered the resident with medication cards belonging to another resident. The resident had taken medications that included amlodipine and carvedilol, which were already prescribed to them, albeit at different dosages, and donepezil, which was not prescribed. The resident's blood pressure was monitored hourly, and when it became elevated, along with symptoms of diaphoresis and clamminess, the on-call physician was contacted, and the resident was sent to the hospital. The investigation revealed that the medication cart was likely left unlocked, allowing the resident to access the medications. The Director of Nursing was notified shortly after the incident, and it was determined that the cart had been left unattended and unlocked, contrary to the facility's policy. The incident was reported to the state agency, and statements were obtained from staff to understand how the resident accessed the medications.
Failure to Ensure Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident requiring BiPAP therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation, did not have a physician's order for BiPAP administration, settings, cleaning, or storage. Observations revealed that the BiPAP machine was not stored in a bag as required, and there was no bag available in the resident's room. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of necessary orders and highlighted lapses in the documentation and storage procedures for the BiPAP equipment. The facility's policies required obtaining a practitioner's order for BiPAP use and settings, following manufacturer instructions for machine use and maintenance, and documenting the resident's response to the therapy. However, these protocols were not followed, as evidenced by the lack of orders and improper storage of the BiPAP machine. Additionally, the staff responsible for managing the BiPAP and oxygen equipment, including the Staffing Coordinator and Certified Nursing Assistants, did not adhere to the facility's guidelines for equipment maintenance and storage, contributing to the deficiency in care provided to the resident.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident with teeth in poor repair. The resident, who was cognitively intact, had obvious or likely cavities or broken natural teeth as noted in their Minimum Data Set (MDS) assessments. Despite being admitted to the facility and having a physician's order indicating the resident may see a dentist as needed, there was no record of any dental visits or care being addressed in the resident's care plan. The resident expressed a desire to see a dentist and reported not having seen one since admission, although they did not experience any tooth pain. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's dental needs. The MDS Coordinator believed the resident had been seen by a dentist but could not find documentation in the Electronic Medical Record (EMR). The Social Services Director (SSD) was unaware of the resident's need for dental care and stated that residents only saw a dentist if there was a specific concern, as there was no routine schedule for dental visits. The Director of Nursing (DON) indicated that the SSD was responsible for ensuring routine dental care and that any dental concerns should be communicated by licensed nurses. However, there was no evidence of such communication or follow-up to ensure the resident received the necessary dental care.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that Resident #1 was free from abuse when Resident #2, who had known aggressive behavior, physically assaulted Resident #1 on two separate occasions. On the first incident, Resident #2 grabbed Resident #1 by the right arm, twisted it, and pushed the resident. Shortly after, Resident #2 approached Resident #1 again and pushed their head into the nurse's station desk. Despite Resident #2's history of verbal and physical aggression, the facility staff did not increase oversight or implement additional measures to prevent further incidents. Resident #2 had a history of mental health issues, including Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder, and had exhibited verbal aggression four to six days during the look-back period. Resident #1, who was severely cognitively impaired and used a wheelchair, had a history of fear related to past neglect and abandonment. The facility's failure to adequately monitor and manage Resident #2's aggressive behavior resulted in harm to Resident #1, highlighting a deficiency in protecting residents from abuse.
Inappropriate Involuntary Transfer Discharge
Penalty
Summary
The facility failed to provide an appropriate involuntary transfer discharge for a resident when they transferred the resident to the hospital and did not allow them to return. The resident, who had diagnoses including Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder, was noted to have moderate cognitive impairment and exhibited verbal and physical aggression. Despite these challenges, the facility did not follow proper procedures for discharge, including failing to provide a 30-day notice or an appeal process to the resident or their representative. The facility's policy required specific documentation and communication when transferring or discharging a resident, including obtaining physician orders, notifying the resident and their representative, and providing detailed transfer forms. However, the facility did not comply with these requirements. The administrator admitted that they did not send adequate discharge information or written physician orders explaining why the facility could not care for the resident and what had been attempted to meet the resident's needs. The resident's care plan indicated that the facility staff was to assess the resident for placement in a specially designed therapeutic unit and intervene as necessary to ensure safety. Despite this, the facility decided not to readmit the resident after their hospital stay, citing the inability to provide adequate care and ensure the safety of others. This decision was made without following the proper discharge procedures, leading to the deficiency noted in the report.
Failure to Ensure PASARR Completion for Resident with Mental Condition
Penalty
Summary
The facility failed to ensure the PreAdmission Screen and Resident Review (PASARR) Level I and, if indicated, Level II was obtained for a resident with a mental condition. The resident, who was admitted from another nursing home, had diagnoses including Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder. The resident's electronic medical record showed no PASARR Level I or Level II, despite the resident exhibiting moderate cognitive impairment, verbal aggression, and requiring anti-anxiety medication daily. The facility's policy mandates that the receiving facility must ensure the PASARR is included in the transfer packet and admission should not be completed without it. However, the Social Service Director (SSD) admitted to not following up on the PASARR request from the prior facility, and the Administrator was unaware of the missing PASARR. The resident's care plan indicated several behavioral issues, including verbal and physical aggression, and outlined interventions such as administering medications, monitoring effectiveness, and assessing the resident for placement in a specially designed therapeutic unit. Despite these documented needs, the lack of a PASARR assessment indicates a failure to comply with federal requirements designed to ensure appropriate placement and care for individuals with mental conditions. The SSD acknowledged the responsibility for ensuring PASARR completion and admitted to not verifying its receipt, while the Administrator confirmed that both he/she and the SSD are responsible for auditing PASARR 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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