Aspire Senior Living Pleasant Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasant Hill, Missouri.
- Location
- 1300 Broadway, Pleasant Hill, Missouri 64080
- CMS Provider Number
- 265565
- Inspections on file
- 31
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aspire Senior Living Pleasant Hill during CMS and state inspections, most recent first.
Two cognitively intact residents with adequate vision, hearing, and clear speech were moved between back and front hall rooms without receiving the written room change notices required by facility policy. In one case, a resident moved to be with a roommate on another unit and was later moved back when the roommate left, with only verbal explanation from SS and no written documentation of the change in the medical record. In the other case, a resident reported being moved due to renovation from a back hall room to a front hall room without written notice, and no room change form was found in the record. The DON and Administrator acknowledged that written notification should have been provided for these room transfers.
A resident with complex medical and psychiatric conditions was not re-admitted after a psychiatric hospital stay, despite being assessed as stable for return. The facility cited ongoing medication noncompliance, aggressive behaviors, and safety concerns for other residents and staff. Staff interviews revealed that the initial admission occurred without complete information, including a missing PASRR, and that the facility was not equipped to manage the resident's needs.
A resident with dementia and VRE required a urinary catheter, but an LPN failed to follow proper catheterization procedures, resulting in pain and bleeding. The LPN did not seek assistance after being unable to insert the catheter and left the resident without completing the procedure or notifying supervisory staff. The resident was later sent to the hospital for evaluation, and the LPN was found to be impaired at the time.
Two residents were affected when a total of 7 mls of Morphine was found missing from their personal supplies, with one bottle showing signs of tampering. The discrepancy was discovered after an LPN suspected of working impaired left the facility during a required narcotics count, prompting an immediate recount by the DON and other nurses. The incident was reported to police, and the facility's required procedures for inventory control and reconciliation of controlled substances were not followed.
A person without a valid RN license was employed as a RN Charge Nurse and provided skilled nursing care, including assessments and medication administration. Discrepancies between the individual's identification and the nursing license were not detected during the hiring process due to inadequate verification procedures. The issue was discovered during a routine audit, revealing that the individual had used another RN's license to obtain employment and had never passed the NCLEX exam.
A resident with cognitive impairments and a history of agitation in crowded areas grabbed and twisted another resident's arm, causing bruising. The incident occurred in a hallway where the aggressive resident was known to block pathways and resist being moved. Staff intervened to separate the residents, and a skin assessment confirmed bruising on the affected resident's forearm.
The facility failed to maintain cleanliness in the kitchen, with food debris and dust accumulation observed, and did not ensure milk was kept at the proper temperature, potentially affecting 77 residents. The Dietary Supervisor lacked a cleaning schedule, and no staff monitored food temperatures in the 500 Unit.
The facility failed to follow infection control practices during wound care, with a wound nurse reapplying a used brief on a resident's clean wound. Staff did not consistently implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices or wounds, and some were unaware of EBP requirements. Additionally, the facility neglected annual TB screenings for some residents and employees, with the DON unaware of these deficiencies.
The facility failed to obtain necessary authorization signatures for managing resident trust accounts, affecting at least four residents. A resident's trust account was opened without their or their POA's signature, and three other residents had funds withdrawn for insurance premiums without their authorization. The Financial Specialist confirmed the absence of required signatures.
The facility failed to provide the required SNFABN and NOMNC to three residents discharged from Medicare Part A services. The Financial Specialist used the incorrect form, believing the Medicare Part B form was the NOMNC form, resulting in residents not receiving proper notice of service termination and their rights. In one case, a resident requested to go home, but no documentation supported this decision.
The facility failed to maintain a clean and homelike environment, with surveyors observing cobwebs, dust, and debris in several resident rooms, affecting 24 residents. Interviews revealed challenges such as residents not allowing thorough cleaning and a shortage of housekeeping staff. Improper storage of soiled items contributed to a pungent odor in a shower room.
The facility failed to maintain safe hot water temperatures, with readings between 126-130°F in residents' rooms, exceeding the recommended 120°F. Additionally, a resident with Parkinson's and blindness was assisted to ambulate without a gait belt, contrary to policy. Furthermore, a smoking assessment was not completed for a resident who smoked daily, leading to a lack of documentation on their ability to smoke safely.
The facility failed to ensure physician's orders for a CPAP machine were documented for a resident with COPD, and did not properly store respiratory equipment for several residents. Observations showed CPAP masks and oxygen tubing left uncovered, contrary to facility policy. Staff interviews confirmed the absence of necessary orders and improper storage practices.
The facility failed to maintain documentation of staff competencies and skills check-offs for CNAs and licensed nursing staff, affecting care for 80 residents with complex needs. The absence of an Assistant Director of Nursing and a staffing coordinator contributed to this deficiency, as confirmed by interviews with a CMT, DON, and LPN. The facility was unable to provide the necessary documentation during the survey.
The facility failed to ensure cleanout covers were securely fitted, posing a hazard to residents and staff on the 100 and 400 Halls. Observations showed loose covers outside a resident's room and between rooms 107 and 108. The Maintenance Director noted no recent work on the cleanouts and relied on housekeeping to report issues. This affected 31 residents.
The facility failed to include two residents in their care plan meetings, as required by policy. One resident with cognitive impairment and another who was cognitively intact were not informed or involved in setting goals for their care plans. Invitations were sent to family members instead, and there was no documentation of the residents' participation. Staff interviews confirmed the lack of adherence to the facility's policy on resident involvement in care planning.
A facility failed to document a resident's DNR status, despite the resident and family member's statements confirming it. The resident's records, including the face sheet, POS, care plan, and EMR, lacked documentation of an advance directive or code status. Interviews with staff revealed a lack of awareness and documentation, with staff believing the resident was a full code. The facility's policy on advance directives was not provided.
A resident with alcohol-induced chronic pancreatitis did not receive prescribed Acamprosate for 21 days due to pharmacy unavailability, and the physician was not notified. Interviews revealed communication lapses among staff, with the LPN and DON unaware of the issue.
The facility failed to provide the bed hold policy to two residents or their representatives when they were discharged to the hospital. One resident was unable to sign the bed hold form, and there was no documentation that the responsible party was informed. Another resident had two hospitalizations without completed bed hold forms. Staff interviews revealed confusion about responsibilities for completing and following up on these forms.
A resident with Down Syndrome and cognitive deficits was not provided with a person-centered activities program. Despite an assessment indicating interests in various activities, the care plan lacked specific goals and interventions. Observations showed the resident was often left unengaged, and staff interviews revealed a lack of awareness of the resident's preferences. The resident participated in activities only twice in a month, failing to meet their psychosocial and physical wellbeing needs.
A facility failed to provide a comprehensive physician's order and care plan for a resident's colostomy care, lacking details on the type and size of supplies needed. Observations and staff interviews revealed insufficient documentation and knowledge about the resident's colostomy management, highlighting a deficiency in care planning and execution.
A resident with a PEG tube did not receive appropriate care as their head of bed (HOB) was consistently positioned at 30 degrees instead of the ordered 45 degrees. Additionally, the water flush bag and tube feeding were not labeled according to facility policy. Staff interviews revealed confusion and lack of adherence to care requirements, contributing to the deficiency.
The facility failed to follow physician's orders for assessing dialysis shunt sites and ensuring communication with the dialysis center for two residents. Incomplete care plans and lack of documentation on dialysis communication compromised care. Staff interviews revealed inconsistent procedures for obtaining and documenting dialysis information.
The facility did not maintain a system for checking food temperatures, leading to scrambled eggs being served at 113 F to residents on the 500 Hall. Staff interviews confirmed that food temperatures had not been checked for at least a month, and the Dietary Supervisor was unsure of tray distribution times.
A resident was subjected to undignified treatment when an RN yelled and cursed at them in the dining room. The incident arose from the RN's inappropriate intervention in the resident's platonic relationship with another resident, despite no concerns from the facility or family. The RN's actions included banging on the table and using profanity, leading to a heated argument.
A resident with a DNR order was resuscitated after a nurse initiated CPR without verifying the resident's code status. The resident was found unresponsive and without a pulse, prompting the nurse to start CPR. The facility's protocol to check code status before CPR was not followed, leading to the resident being resuscitated and later passing away in the hospital.
Failure to Provide Required Written Notices for Resident Room Changes
Penalty
Summary
Surveyors found that the facility failed to provide required written notification of room changes for two cognitively intact residents who were moved between the back and front halls of the building. Facility policy stated that residents and their representatives must receive advance written notice of any room or roommate change, including the reasons for the move, and that Social Services (SS) would assist with adjustment by informing residents and families as soon as possible. For one resident admitted in November, the annual MDS showed the resident had clear speech, adequate vision and hearing, and was cognitively intact, originally residing on the back hall. Observation later showed the resident living in a front hall room, but the medical record contained no written room change notice. The resident reported moving to the back unit to be with a roommate who later went to the hospital and did not return, after which staff moved the resident back to the front. The resident stated they were not given written notice of the room change, though they had spoken with SS about it. SS confirmed that no written room change notice was provided for this resident, explaining that the prior management company had not used written notices and that the new company, which took over in October, did have a room change form. SS stated the resident had been back on the front hall for about six weeks and that the resident had been told verbally that a move back to the front would occur if the roommate left the facility. In a second case, another cognitively intact resident with adequate vision, hearing, and clear speech was documented on a quarterly MDS as residing on the back hall, but observation showed the resident in a front hall room, and the medical record contained no room change notice. This resident reported being moved from the back to the front a couple of weeks earlier due to renovation and stated no written notice was given. The DON and Administrator stated they would have expected written notification for these room changes and initially suggested notices might be awaiting scanning into the electronic record, but as of the survey date no such notices had been produced.
Failure to Re-Admit Resident After Psychiatric Hospitalization Due to Safety Concerns and Incomplete Pre-Admission Assessment
Penalty
Summary
The facility failed to re-admit a resident following an inpatient psychiatric hospital stay, despite documentation from the psychiatric hospital indicating the resident was stable enough to return. The resident had a complex medical and psychiatric history, including high blood pressure, colostomy, vascular dementia, bipolar disorder, schizophrenia, and mood disorder. The facility issued an emergency discharge notice, citing concerns for the safety of other residents and staff due to the resident's medication noncompliance, aggressive behaviors, and continued agitation both prior to and during the hospital stay. The discharge notice was sent to the resident, their guardian, and the Ombudsman, and stated that the discharge was necessary for the safety of all residents, with the right to appeal outlined, but the discharge was already effectuated. Interviews with facility staff revealed that there were significant concerns and a lack of adequate information at the time of the resident's initial admission. The Admissions/Marketing Coordinator and DON noted that the referral was flagged as requiring further evaluation due to behavioral history, but they were unable to obtain the resident's PASRR or sufficient medical records from the hospital. Despite their concerns and an unsuccessful on-site evaluation, the regional admissions staff accepted the resident for admission. The facility administrator acknowledged that the facility was not equipped to provide the necessary care for the resident and that the initial admission should not have occurred. The Ombudsman confirmed involvement with the resident and expressed surprise that the facility had accepted the resident initially, given the behavioral and mental health history. The Ombudsman also noted the lack of a recent PASRR and believed the facility did not have accurate information prior to admission. The facility's decision to refuse re-admission after the psychiatric hospitalization was based on ongoing concerns for the safety of other residents and staff, as well as the resident's continued noncompliance and behavioral issues.
Improper Urinary Catheter Insertion Resulting in Resident Pain and Bleeding
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to perform urinary catheter placement according to the facility's established standards of practice. The facility's procedures required that catheters be inserted by licensed nurses under physician orders, with specific steps for sterilization, lubrication, and gentle insertion, and clear instructions not to force the catheter if resistance was met. In this incident, the LPN attempted to insert a urinary catheter for a resident with neurocognitive disorder, dementia, and a history of vancomycin-resistant enterococci (VRE) in the urine, but was unsuccessful and left the resident in pain with blood present on the bed and in the resident's brief. The resident, who was moderately cognitively intact according to the most recent assessment, reported to another nurse that the catheterization attempt was painful and resulted in bleeding. The nurse who discovered the situation noted the absence of a catheter bag, the presence of blood, and that the resident stated the LPN had tried but failed to insert the catheter, causing pain. The incident was further corroborated by a police report and statements from staff, indicating that the LPN left the room after the unsuccessful attempt without seeking assistance or notifying supervisory staff as required by protocol. Following the event, the resident was transported to the hospital for evaluation due to pain and bleeding, though no trauma was ultimately found. The investigation determined that the LPN appeared to be impaired at the time of the incident and did not follow proper procedures for catheter insertion, including not seeking help when encountering difficulty. The facility's leadership confirmed that the LPN should not have attempted the procedure under those circumstances and failed to follow expected protocols.
Failure to Maintain Controlled Substance Accountability Resulting in Missing Narcotics
Penalty
Summary
The facility failed to maintain proper control and accountability of controlled substances, specifically Morphine, for two residents. According to the facility's policy, staff were required to keep accurate declining inventory records, reconcile counts at each shift change, and immediately report and investigate any discrepancies. However, a discrepancy was discovered when a total of 7 milliliters of Morphine was found missing from the personal supplies of two residents. The missing amounts included 3 milliliters from one resident and 4 milliliters from another, with one of the bottles having a tampered seal and never having been used by the resident. One resident involved had diagnoses including congestive heart failure, dilated cardiomyopathy, and COPD, and was cognitively intact at the time of the incident. This resident reported using Morphine primarily for shortness of breath and was unaware of any missing doses. The other resident had a history of pneumonia and chronic respiratory failure with hypoxia and was severely cognitively impaired. This resident no longer had an active order for Morphine at the time of the incident. The events leading to the deficiency included a report that an LPN was suspected of working while impaired. When asked to participate in a narcotics count, the LPN handed over their keys and left the facility. An immediate recount by the DON and other nurses revealed the discrepancies in the Morphine counts. The incident was reported to the police, and it was noted that the Morphine bottles had been tampered with and secured to prevent further access.
Unlicensed Individual Employed as RN and Provided Nursing Care
Penalty
Summary
The facility failed to ensure that an individual employed as a Registered Nurse (RN) possessed a valid RN license in accordance with state laws. The individual, referred to as Unlicensed RN A, was employed as a RN Charge Nurse and provided skilled nursing care, including assessments, wound care, medication administration, and other nursing services. During a routine audit, discrepancies were found between the name on the state-issued identification and the name on the nursing license provided by Unlicensed RN A. Further investigation revealed that the license number given did not match the individual's social security number or date of birth, and no valid RN license could be found for this person in any state. Unlicensed RN A admitted to having taken the National Council Licensure Examination (NCLEX) but failed the exam and never retook it. The individual also acknowledged using a license belonging to another RN with a similar name to obtain employment. Throughout the period of employment, Unlicensed RN A was responsible for carrying out physician's orders, completing skilled nursing assessments, and overseeing the care provided by other staff. The facility's onboarding process at the time did not include adequate verification steps to ensure that the name on the professional license matched the name on government-issued documents, which allowed the unlicensed individual to be hired and work as a RN. Interviews with facility staff indicated that the responsibility for verifying new hire documentation, including licensure, was assigned to the Staff Development Coordinator, who failed to identify the discrepancies. There was no auditing process or checklist in place for new hire paperwork, and the lack of double-checking allowed the deficiency to go undetected for an extended period. The issue was discovered only after a routine audit by the facility's Wound Nurse, which prompted an internal investigation and subsequent reporting to the appropriate authorities.
Resident-to-Resident Altercation Results in Bruising
Penalty
Summary
The facility failed to protect a resident from abuse when another resident grabbed and twisted their arm, resulting in bruising. On the day of the incident, a resident with cerebral palsy, intellectual disabilities, and severe cognitive impairment was observed in the hallway tapping other residents as they passed by. This resident, who uses a wheelchair and requires assistance with daily activities, was seen swinging their arms and later grabbed another resident's arm, causing bruising. The resident who was grabbed has dementia with behavioral disturbances and also uses a wheelchair. Staff interviews revealed that the resident who grabbed the arm often becomes agitated when others try to pass them in crowded areas, such as hallways or dining areas. The resident was known to deliberately block pathways and resist being moved, which could lead to physical aggression. On the day of the incident, staff had to move the resident out of the entryway, which may have contributed to their agitation and subsequent aggressive behavior. The incident was witnessed by staff, who intervened to separate the residents. A skin assessment was conducted on the resident who was grabbed, revealing bruising on their forearm. Despite the incident, the resident who was grabbed expressed feeling safe in the facility and did not believe the other resident intended harm. However, the facility's failure to prevent the altercation and protect the resident from harm constitutes a deficiency in resident safety and protection from abuse.
Deficiencies in Kitchen Cleanliness and Food Temperature Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage standards in the kitchen and dining areas, potentially affecting 77 residents. Observations revealed food crumbs and an old orange behind canned goods storage, crumbs near the chest freezer, dust on the ceiling vent over the food preparation table, grime and food debris behind the ice machine, and a heavy buildup of bread crumbs in the toaster. Additionally, dust was found on the kitchen fan. Interviews with the Dietary Supervisor indicated a lack of regular cleaning in the dry goods storage room and an absence of a cleaning schedule for the toaster. The Housekeeping Supervisor acknowledged the difficulty in cleaning behind the ice machine, and the Administrator noted the need for a cleaning plan. The facility also failed to maintain the proper temperature for milk served to residents in the 500 Hall, with a recorded temperature of 50.1 F, above the recommended 41 F. The Activities' Director confirmed that no dietary staff were checking food temperatures in the 500 Unit. The Dietary Supervisor admitted that no one was monitoring the milk temperature, and the ice bath used to keep the milk cool was melting, leading to improper temperature maintenance.
Infection Control and EBP Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with an open wound on the left buttocks. The wound nurse, unaware of the potential for cross-contamination, reapplied a used incontinent brief after cleaning the wound, instead of using a clean one. This oversight was acknowledged by the wound nurse and the Director of Nursing (DON), who both recognized the importance of using a clean brief to protect the wound from contamination. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) consistently for residents requiring such measures. Several staff members, including CNAs and LPNs, failed to wear gowns and gloves during high-contact care activities for residents with indwelling devices or wounds. Some staff were unaware of the EBP requirements, mistaking them for COVID-19 precautions, and did not follow proper hand hygiene protocols. The DON was not aware of these lapses in EBP adherence. The facility also neglected to complete annual Tuberculosis (TB) screenings for some residents and employees. Several employees did not have documented TB tests upon hire, and some residents did not receive their annual TB tests. The Infection Preventionist and nursing staff were responsible for these screenings but failed to ensure they were completed timely. The DON was unaware of these deficiencies, indicating a lack of oversight in the facility's infection control program.
Failure to Obtain Authorization for Resident Trust Accounts
Penalty
Summary
The facility failed to obtain necessary authorization signatures for the management of resident trust accounts, affecting at least four residents. Specifically, the facility did not secure a signature from Resident #50 or their Power of Attorney (POA) for the opening of a resident trust account. Despite communication with the POA, the form was returned unsigned, and no further outreach was conducted by the facility. This oversight led to the unauthorized opening of the trust account. Additionally, the facility did not obtain authorization signatures from Residents #100, #41, and #62 for transactions involving Supplemental Insurance Company A. Checks were written from these residents' trust accounts for insurance premiums without their signatures or authorization. The Financial Specialist confirmed the absence of signatures and noted that the facility was responsible for obtaining them when residents first signed up with the insurance company. This lack of proper authorization documentation resulted in unauthorized withdrawals from the residents' trust accounts.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and/or the Notice of Medicare Provider Non-Coverage (NOMNC) to three residents who were discharged from Medicare Part A services. The deficiency was identified for three residents out of a sample of three, indicating a systemic issue. The NOMNC, which informs residents of the termination of Medicare-covered services and their right to an expedited review, was not provided to the residents or their responsible parties. This failure was due to the Financial Specialist using the incorrect form, mistakenly believing that the Medicare Part B form was the NOMNC form. The Financial Specialist, responsible for issuing these notices, admitted to providing the wrong form and was unaware of the correct procedure. The residents were supposed to receive a 48-hour notice prior to the discharge date, but this was not properly executed. In one case, a resident requested to go home, and no forms were provided, with no documentation in the electronic medical record to support the resident's decision to self-discharge. This oversight highlights a lack of proper training and understanding of the notification process, leading to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms, as observed during a survey. Specific deficiencies included a heavy buildup of cobwebs, dust, and food debris in various rooms, affecting the living conditions of 24 residents. Observations revealed cobwebs between climate control units and nightstands, food crumbs in corners, dust on fans, and debris such as grass clippings and grime on floors. Additionally, there was a pungent urine odor in the 300 Hall shower room due to a trash container with soiled items being improperly stored there. Interviews with facility staff highlighted issues contributing to the deficiencies. The Housekeeping Supervisor acknowledged the challenges faced by housekeepers, such as residents not allowing them to move items for thorough cleaning and a shortage of housekeeping staff earlier in the year. The supervisor also noted that the trash container should have been in the soiled utility room, not the shower room. The Administrator was unaware of the presence and duration of an old plastic pink bedpan under a resident's bed, indicating a lack of oversight in maintaining cleanliness standards.
Deficiencies in Hot Water Safety, Gait Belt Use, and Smoking Assessment
Penalty
Summary
The facility failed to maintain safe hot water temperatures in the rooms of several residents, with temperatures recorded between 126-130 degrees Fahrenheit, exceeding the recommended maximum of 120 degrees Fahrenheit. This issue was observed in the rooms of residents who had varying levels of cognitive and physical impairments, making them potentially vulnerable to burns or scalds. The Maintenance Director acknowledged the high setting of the hot water heater, which also served the laundry, and admitted that it did not need to be set so high. Additionally, the facility did not adhere to its policy regarding the use of gait belts for resident assistance. A resident with Parkinson's disease and blindness, who was unsteady on their feet, was assisted to ambulate without the use of a gait belt. The CNA assisting the resident did not have a gait belt available and acknowledged the oversight. The LPN observed the situation and provided a gait belt after the resident had already been assisted to the bathroom. The facility also failed to complete an initial smoking assessment for a resident who was a daily smoker. The resident's care plan indicated the need for staff observation while smoking, but there was no documentation of an assessment to determine the resident's ability to smoke safely. Interviews with staff revealed confusion about the responsibility for completing smoking assessments, with discrepancies between the roles of the Social Services Director and nursing staff.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure that physician's orders for a CPAP machine were included in the Physician's Order Sheet (POS) and care plan for a resident with COPD. The resident's care plan did not include the use and care of the CPAP machine, and there was no documentation of the resident's use of the CPAP machine at bedtime or as needed. Observations showed the CPAP machine and mask were left uncovered, and interviews with staff confirmed the absence of a physician's order for the CPAP machine. Additionally, the facility did not maintain proper storage for respiratory equipment for several residents. Observations revealed that CPAP masks and oxygen tubing were left uncovered and not stored in bags when not in use. This was noted for multiple residents, including those with diagnoses of COPD and sleep apnea. The facility's policy required that such equipment be stored in plastic bags to prevent contamination, but this was not adhered to. Interviews with staff, including CNAs and the DON, indicated an expectation for physician orders for CPAP and oxygen therapy, as well as proper storage of equipment. However, these expectations were not met, as evidenced by the lack of orders and improper storage practices observed during the survey.
Lack of Staff Competency Documentation in Facility
Penalty
Summary
The facility failed to maintain documentation and ensure that Certified Nursing Assistants (CNAs) and licensed nursing staff had the appropriate competencies and skills check-off completed annually and as needed. This deficiency was identified during a survey where it was noted that the facility did not have an Assistant Director of Nursing (ADON) and lacked a staffing coordinator responsible for coordinating competency and skills check-offs. The facility census was 80 residents, including those with complex medical needs such as tracheostomies, wounds, colostomies, Foley catheters, tube feeding, and dialysis. During interviews, it was revealed that a Certified Medication Technician (CMT) had completed a competency skills check-off 4-5 months prior but did not retain a copy. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the absence of a staffing coordinator and the inability to locate the staff competency and skills documentation. The DON stated that the staffing coordinator would typically manage the skills lab and maintain documentation, but due to the vacancy, these responsibilities were not fulfilled. At the time of the survey exit, the facility administration was still unable to provide the required documentation.
Loose Cleanout Covers Pose Hazard
Penalty
Summary
The facility failed to maintain the covers of cleanouts in a tight-fitting manner, creating a potential hazard for residents and staff on the 100 Hall and 400 Hall. Observations on two separate occasions revealed that the cleanout cover outside a resident's room and the cover between rooms 107 and 108 were loose when stepped on. During an interview, the Maintenance Director stated that no work had been done around the cleanout since April 2024 and expected housekeeping staff to report any loose covers. This deficiency potentially affected 31 residents residing on those halls.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #59 and Resident #75, were included in their care plan meetings and were not provided with invitations to these meetings. Resident #59, who had some cognitive impairment, was not aware of care plan meetings, had not been involved in setting goals, and had not seen their care plan. The care plan meeting invitations were addressed to the resident's family member, with no documentation showing that the resident was presented with these invitations or that they attended the meetings. Similarly, Resident #75, who was cognitively intact, was not informed of care plan meetings, had not been invited, and was not involved in setting goals. The care plan meeting invitations were also addressed to the resident's family member, with no documentation indicating that the resident was presented with these invitations or that they attended the meetings. The facility's policy required that residents be involved in the development and implementation of their person-centered care plans, but this was not adhered to in these cases. Interviews with facility staff, including the Social Service Director (SSD), MDS nurse, and Director of Nursing (DON), revealed that care plan meeting invitations were typically sent to family members, and residents were not routinely given these invitations. The SSD and MDS nurse acknowledged that documentation of care plan meetings was lacking, and the comprehensive care plans were not reviewed with residents. The DON expected residents to participate in their care plans, but this expectation was not met for the two residents in question.
Failure to Document Resident's DNR Status
Penalty
Summary
The facility failed to ensure the correct code status was in place for one resident, identified as Resident #28, out of a sample of 22 residents. The resident was admitted to the facility with a diagnosis of orthopedic aftercare and was cognitively intact. However, the resident's face sheet, Physician Order Sheet (POS), care plan, and Electronic Medical Record (EMR) all lacked documentation of an advance directive or code status. Despite the resident and a family member stating that the resident was a Do Not Resuscitate (DNR), the facility records did not reflect this status. Interviews with facility staff, including a Social Services Designee (SSD), a Certified Nursing Assistant (CNA), a Registered Nurse (RN), and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's DNR status. The staff believed the resident was a full code, indicating that resuscitation should be performed if necessary. The facility's policy on advance directives was requested but not provided, further highlighting the deficiency in ensuring the resident's rights to have their code status accurately documented and respected.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to notify the physician when medication could not be obtained from the pharmacy for a resident diagnosed with alcohol-induced chronic pancreatitis and alcohol abuse with other-induced disorder. The resident was prescribed Acamprosate 333 mg, to be taken two tablets three times daily, but the medication was not administered for 21 out of 31 days in the month due to unavailability from the pharmacy. There was no documentation indicating that the resident's physician was notified about the medication's unavailability and non-administration. Interviews with facility staff revealed a breakdown in communication and procedure. The Licensed Practical Nurse (LPN) stated that the Certified Medication Technician (CMT) or a nurse could reorder the medication from the pharmacy and notify the physician if the medication could not be filled. However, the LPN was not informed by any CMTs about the medication's unavailability. The Director of Nursing (DON) expected the charge nurse to be notified and to contact the physician if a medication was unavailable, but was unaware that the resident had not received the medication.
Failure to Provide Bed Hold Policy to Residents
Penalty
Summary
The facility failed to ensure that residents or their representatives were provided with the bed hold policy or educated on it in a timely manner when residents were discharged to the hospital. This deficiency was identified for two residents out of a sample of 22. For Resident #8, the physician ordered a transfer to the hospital, but the resident was unable to sign the bed hold form. The responsible party was notified of the transfer, but there was no documentation that the bed hold form was completed, signed, or sent to the responsible party. The facility's administrator confirmed the absence of the bed hold document in the resident's records. For Resident #5, who had moderately impaired cognition, there were two hospitalizations, but no documentation of a completed or signed bed hold form for either discharge. Interviews with facility staff revealed confusion and lack of clarity regarding the responsibility for completing and following up on bed hold forms. The Director of Nursing and the Regional Corporate Nurse indicated that charge nurses were responsible for completing the forms, and the Social Services Designee was expected to ensure their completion and notify the responsible party if the resident was unable to sign. However, the bed hold forms were not completed for Resident #5, as the family reportedly declined the bed hold, although the DON later stated that the resident would be the one to decline it.
Failure to Provide Person-Centered Activities Program
Penalty
Summary
The facility failed to provide a person-centered activities program tailored to the interests and abilities of a resident with Down Syndrome and cognitive communication deficits. The resident's activity assessment indicated interests in games, socialization, one-on-one activities, cognitive learning, arts and crafts, music, and exercise, with goals of attending at least three activities weekly. However, the resident's care plan lacked specific information about preferred activities, goals, and interventions. Observations showed the resident was often left sitting near the nurse's station without engagement in activities, and staff did not offer the resident items for recreational use or invite them to participate in activities. Interviews with staff revealed a lack of awareness of the resident's activity preferences and insufficient efforts to engage the resident in meaningful activities. The Activities Director and DON acknowledged the expectation for staff to provide appropriate mental and physical stimulation and to offer individualized activities when group activities were not suitable. Despite these expectations, the resident participated in activities only twice in a month, indicating a significant deficiency in meeting the resident's psychosocial and physical wellbeing needs.
Lack of Comprehensive Colostomy Care Plan and Orders
Penalty
Summary
The facility failed to provide a comprehensive physician's order for colostomy care for a resident, which included necessary details such as the type and size of ostomy supplies needed. The resident, who was cognitively intact and had a colostomy upon admission, did not have a detailed care plan or physician's order specifying the monitoring, care of the stoma, or when to change the colostomy pouch and wafer. Observations revealed that the colostomy collection pouch contained loose stool, and interviews with staff indicated a lack of knowledge about the specific type or size of supplies required for the resident's colostomy. Interviews with various staff members, including CNAs, an RN, the MDS Coordinator, and the DON, highlighted the absence of detailed documentation and orders for the resident's colostomy care. The staff expressed expectations for comprehensive physician orders and care plans, but these were not in place. The deficiency was identified through a review of the resident's medical records, which confirmed the lack of detailed orders and care plans necessary for proper colostomy management.
Failure to Ensure Proper Care for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a Percutaneous Endoscopic Gastronomy (PEG) tube. The resident, who was non-verbal and received more than 51% of their daily nutrition through tube feeding, had specific physician orders requiring their head of bed (HOB) to be elevated to 45 degrees at all times due to the tube feeding. However, observations over several days showed the resident's HOB was consistently at approximately 30 degrees, contrary to the physician's orders. Additionally, the water flush bag was not labeled as required by the facility's policy, and the tube feeding was not labeled with a start time on multiple occasions. Interviews with facility staff revealed a lack of awareness and adherence to the specific care requirements for the resident. A Certified Nursing Assistant (CNA) incorrectly stated that the HOB should be elevated to 30 degrees, while a Registered Nurse (RN) was unsure about the labeling requirements for the water flush bag and the specific HOB positioning order. The Director of Nursing (DON) confirmed the expectations for labeling and HOB positioning but noted that the resident's order needed updating to reflect a range of 30 to 45 degrees. The failure to follow the physician's orders and facility policies resulted in a deficiency in the care provided to the resident with a PEG tube.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care for two residents, as evidenced by not following physician's orders for assessing dialysis shunt sites and ensuring proper communication with the dialysis center. For one resident, the facility did not consistently assess the dialysis shunt for bruit and thrill every shift as ordered, and there were multiple instances where the absence of these indicators was not reported to the physician. Additionally, the facility did not document return communication from the dialysis center, which should have included vital information such as pre and post weights, vital signs, and any complications during dialysis treatments. The care plans for the residents were incomplete, lacking critical information about the dialysis access site, the type of dialysis, and specific care instructions. This omission extended to the absence of documentation regarding the coordination of care between the facility and the dialysis provider. The facility's failure to maintain comprehensive care plans and ensure proper communication with the dialysis center compromised the continuum of care for the residents. Interviews with staff revealed a lack of consistent procedures for obtaining and documenting dialysis communication. Staff admitted to not always receiving or following up on dialysis communication forms, and there was an acknowledgment of issues with the dialysis center's compliance in providing necessary information. Despite the residents' known medical conditions, such as low blood pressure affecting the ability to assess the shunt site, the facility did not adequately address these challenges in their care plans or daily practices.
Failure to Maintain Food Temperature Checks
Penalty
Summary
The facility failed to maintain a regular system for checking food temperatures, resulting in scrambled eggs being served at an inadequate temperature of 113 F to residents on the 500 Hall. Observations revealed that the food cart left the kitchen at 7:31 A.M., and trays were distributed between 7:34 A.M. and 7:45 A.M. However, the temperature of the eggs was not checked by the dietary department during this time. Interviews with staff, including a CNA, an RN, and a dietary staff member, confirmed that food temperatures had not been checked on the 500 Unit for at least a month. The Dietary Supervisor was also unsure of how long trays sat before being distributed, indicating a lack of oversight in ensuring food safety and quality.
Resident Dignity Violated by RN's Inappropriate Behavior
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a Registered Nurse (RN) cursed and yelled at the resident in the dining room. The incident involved a resident who was cognitively intact and able to make their wants and needs known. The resident had a history of hyperlipidemia and had undergone aortocoronary bypass graft surgery. The altercation occurred when the resident was holding hands with another resident, which led RN A to intervene inappropriately by banging on the table and using profanity. The RN's actions were perceived as an attempt to control the resident's interactions with another resident, despite there being no concerns from the facility, family, or physician about the platonic relationship. The RN's behavior was described as rude and involved telling the resident what they could and couldn't do, which escalated into a heated argument in the presence of other residents. The incident was reported to the facility's administration, and the RN was subsequently suspended and terminated for violating facility policy.
Failure to Verify DNR Status Before CPR
Penalty
Summary
The facility failed to verify a resident's Do Not Resuscitate (DNR) status before initiating cardiopulmonary resuscitation (CPR). A registered nurse (RN) found the resident unresponsive, without a pulse or spontaneous respirations, and began CPR without checking the resident's code status. The resident, who had a DNR order, was resuscitated and transported to the hospital, where they later died after being placed on comfort care. The resident had a documented DNR status in their electronic medical record and hard copy chart, which was not checked before CPR was initiated. The facility's protocol required staff to verify a resident's code status before starting CPR, but this step was overlooked in the emergency situation. The RN involved stated that their immediate response was to address the medical emergency without considering the resident's end-of-life wishes. Interviews with facility staff revealed that the resident's code status could be accessed in the electronic record and hard chart, but there was confusion and delay in verifying this information during the emergency. The incident highlighted a breakdown in communication and adherence to protocol, resulting in the failure to honor the resident's DNR order.
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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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