Aspire Senior Living Poplar Bluff
Inspection history, citations, penalties and survey trends for this long-term care facility in Poplar Bluff, Missouri.
- Location
- 3001 May Street, Poplar Bluff, Missouri 63901
- CMS Provider Number
- 265450
- Inspections on file
- 17
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aspire Senior Living Poplar Bluff during CMS and state inspections, most recent first.
A resident with multiple cardiac, respiratory, neurologic, and other chronic conditions had numerous prescribed medications, including Eliquis, Lasix, Midodrine, Methocarbamol, Gabapentin, Protonix, a protein supplement, Finasteride, and PRN Hydrocodone-Acetaminophen. Review of the MAR and progress notes showed that several scheduled doses of these medications were not administered and were repeatedly documented as "on order," indicating they were not available. Facility policy required staff to determine the cause and duration of unavailability, contact the pharmacy, notify the physician, obtain alternative or monitoring orders, and treat missed doses as medication errors with appropriate notifications and monitoring, but the report contains no evidence these steps were taken. In interviews, the DON, Administrator, and FNP all stated they expected nursing staff to follow this policy and notify the prescriber when medications were unavailable, confirming that these actions did not occur.
A resident with multiple psychiatric diagnoses did not receive a scheduled IM injection of Invega Sustenna because the order was entered on the CMT MAR, and the CMT, who could not administer the injection, failed to notify the charge nurse. The missed dose was not documented or reported, and the DON only became aware after the resident's family inquired.
A facility failed to assess and document the use of a merry walker for a resident with severe cognitive impairment, leading to a deficiency in ensuring the resident was free from physical restraints unless medically necessary. The resident's medical records lacked documentation of alternatives tried, the least restrictive use, and ongoing re-evaluations. Interviews with staff revealed an expectation for quarterly assessments, which were not conducted, resulting in the deficiency.
The facility failed to provide scheduled showers for three residents, leading to missed opportunities for personal hygiene care. A resident missed nine out of eleven scheduled showers, while two other residents missed six out of eleven. Observations showed unkempt grooming, and interviews confirmed the issue, with staff acknowledging the problem.
A resident with spinal stenosis and total dependence on staff for transfers was not transferred using a gait belt as required by facility policy. Instead, a CNA lifted the resident under the arms, causing potential harm. The facility's policy mandates the use of a gait belt or a Hoyer lift if the resident experiences pain or cannot bear weight.
A resident with severe cognitive impairment and total dependence on staff for personal hygiene was left without incontinence care for over six hours, resulting in a soaked brief with dark urine and a strong odor. The facility's policy required checks every two hours, but this was not followed, leading to the deficiency.
A resident's G-tube was replaced in the ER, but upon return to the facility, staff failed to assess the tube, leading to a misunderstanding that it was a urinary catheter. This resulted in the resident's feedings and flushes being held for 11 days without a physician's order. The DON did not verify the tube type or review discharge paperwork, and the physician was not informed until much later. The resident, who could eat orally, did not suffer immediate harm, but the facility's actions posed a risk to their nutritional needs.
A facility failed to document and monitor dialysis care for a resident with ESRD. The resident lacked physician orders for dialysis and assessments of the dialysis site and vital signs were inconsistently documented. Despite using a Dialysis Communication form, multiple instances of incomplete documentation were noted, indicating a failure to adhere to the facility's policy.
The facility failed to limit PRN orders for psychotropic medications to 14 days for three residents, despite pharmacy requests for stop dates. A resident with restlessness and insomnia, another with COPD and anxiety, and a third with an anxiety disorder had PRN orders without 14-day stop dates. The DON had not completed necessary reviews due to other duties, and the facility lacked a policy for 14-day stop dates.
The facility failed to properly label and store medications, with insulin pens found undated and a medication cart left unlocked and unattended. Staff interviews confirmed that carts should be locked and insulin dated, but these practices were not followed, affecting all residents.
The facility did not update its facility-wide assessment annually, failing to include a resident with a feeding tube and inaccurately reporting the number of residents with intellectual disabilities. The assessment was based on an incorrect census, affecting the identification of necessary resources for resident care.
The facility failed to maintain proper infection control practices during meal pass, incontinent care, and medication administration, with staff not performing hand hygiene or changing gloves as required. Additionally, the facility did not correctly screen residents for tuberculosis, missing or incomplete screenings were noted in medical records.
Failure to Administer Ordered Medications and Notify Prescriber When Drugs Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed medications as ordered and to notify the prescriber when medications were unavailable for one resident out of three sampled, in violation of the facility’s own policy on unavailable medications. The facility’s policy required staff to determine the reason and duration of medication unavailability, document efforts to obtain the medications, notify the physician when medications were not available, obtain alternative treatment or monitoring orders, and treat missed doses as medication errors with appropriate notifications and monitoring. These required actions were not carried out as specified in the policy. The affected resident had multiple significant diagnoses, including atrial fibrillation, atherosclerotic heart disease, hypertension, venous thrombosis and embolism, pulmonary embolism, pulmonary hypertension, osteoarthritis, anemia, orthostatic hypotension, myocardial infarction, benign prostatic hyperplasia, GERD, sciatica, neuropathy, congestive heart failure, postural orthostatic tachycardia syndrome, chronic respiratory failure, cellulitis of the left lower leg, and unstable angina. Physician orders dated in February 2026 included Eliquis, Midodrine, protein supplement, Methocarbamol, Finasteride, Lasix, Hydrocodone-Acetaminophen, Protonix, and Gabapentin. The Medication Administration Record for that month showed multiple missed doses: Eliquis, Gabapentin, Hydrocodone-Acetaminophen, Lasix, Protonix, and Midodrine each had missed administrations, and Methocarbamol and the protein supplement had multiple missed opportunities. Progress notes documented that upon the resident’s admission and over the following days, numerous ordered medications, including Eliquis, Midodrine, Methocarbamol, Finasteride, protein supplement, Hydrocodone-Acetaminophen, Lasix, Gabapentin, and Protonix, were repeatedly noted as “on order,” indicating they were not available for administration at the scheduled times. There is no documentation in the report that staff followed the facility’s policy to notify the physician or family, obtain alternative orders, or complete medication error reports for these missed doses. In interviews, the DON, Administrator, and Family Nurse Practitioner each stated they would have expected nursing staff to notify the pharmacy and prescriber when medications were not available and to follow the facility’s policy, confirming that these expectations were not met in this case.
Failure to Administer Medication as Ordered Due to Communication and Documentation Errors
Penalty
Summary
The facility failed to follow physician's orders for one resident by not administering a prescribed medication, Invega Sustenna, in a timely manner. The resident, who had diagnoses including dementia, schizoaffective disorder, anxiety, depression, and persistent mood disorder, had a physician's order for an intramuscular injection of Invega Sustenna to be given on a specific date each month. On the scheduled date, the medication order was entered into the medical record in such a way that it appeared on the Certified Medication Technician (CMT) Medication Administration Record (MAR), even though a CMT is not authorized to administer this injection. The CMT documented that the medication was not given but did not notify the charge nurse, as required by facility policy. The charge nurse on duty was not informed that the medication had not been administered, and there was no documentation in the resident's progress notes indicating that the missed dose was reported or addressed. The Director of Nursing was unaware of the missed administration until contacted by the resident's family. The failure to communicate and follow up on the missed medication resulted in the resident not receiving the prescribed injection as ordered by the physician.
Failure to Assess and Document Merry Walker Use as a Restraint
Penalty
Summary
The facility failed to properly assess and document the use of a merry walker for a resident, leading to a deficiency in ensuring the resident was free from physical restraints unless medically necessary. The resident, who had severe cognitive impairment and multiple diagnoses including intellectual disability and mood disorder, was using a merry walker due to an unsteady gait and inability to ambulate independently. However, the facility did not conduct an assessment to determine if the merry walker was being used as a restraint, nor did they document any ongoing re-evaluation of its use. The resident's medical records lacked documentation of alternatives tried before resorting to the merry walker, the least restrictive use of the device, and ongoing re-evaluations. Additionally, there was no consent documented for the use of the merry walker as a restraint. Observations showed the resident frequently sat in the merry walker and was assisted by staff for various activities, indicating a potential reliance on the device without proper assessment. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed an expectation for quarterly assessments and documentation regarding the use of the merry walker as a restraint. However, these assessments were not conducted, and the necessary documentation was not maintained, leading to the deficiency identified by the surveyors.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for three residents, resulting in a deficiency in the care and assistance for activities of daily living (ADLs). Resident #5, who is dependent on staff for personal hygiene and showers, missed nine out of eleven scheduled shower opportunities and ten out of eleven opportunities for facial shaving and hair washing. Observations showed the resident with unkempt facial hair and dry skin flakes, and the resident expressed dissatisfaction with their grooming. The care plan for Resident #5 did not address the frequency or assistance required for showers, contributing to the missed care. Similarly, Resident #24 and Resident #32 also did not receive their scheduled showers. Resident #24 missed six out of eleven scheduled showers, and Resident #32 missed six out of eleven scheduled showers, with both residents' care plans lacking details on shower frequency and assistance. Interviews with the residents and staff, including the Administrator and Director of Nursing, confirmed the issue of incomplete showers, with staff acknowledging the problem and the facility attempting to find a solution.
Failure to Use Gait Belt for Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as Resident #29, by not utilizing a gait belt as required by the facility's policy. The resident, who was moderately cognitively impaired and totally dependent on staff for mobility and transfers, experienced significant pain during an attempted transfer with a gait belt. The Certified Nursing Assistant (CNA) involved decided to transfer the resident without the gait belt, using an alternative method that involved lifting the resident under the arms, which is against the facility's policy and could potentially cause harm. The resident's medical history included spinal stenosis, muscle weakness, and a history of a wedge compression fracture, which contributed to their total dependence on staff for transfers. The facility's policy mandates the use of a gait belt for all transfers unless alternative methods are required due to pain or inability to bear weight, in which case a Hoyer lift should be used. Interviews with staff, including the Certified Occupational Therapy Assistant (COTA) and the Director of Nursing (DON), confirmed that the proper procedure was not followed, as a Hoyer lift should have been used instead of lifting the resident under the arms.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bowel and bladder, resulting in the resident being left without personal care for over six hours. The resident, who had severe cognitive impairment and was totally dependent on staff for personal hygiene, was observed with a brief soaked with dark urine and a strong urine odor. The facility's policy required residents to receive necessary services to maintain personal hygiene, but the resident's care plan did not address incontinence care. On the day of the incident, the resident was observed in various locations within the facility from morning until afternoon without being checked for incontinence. The Certified Nursing Assistant (CNA) assigned to the resident's hall confirmed that the resident was not changed until 2:48 P.M., despite being up since 6:45 A.M. The facility's Administrator and Director of Nursing both stated that residents should be checked for incontinence every two hours, which was not adhered to in this case.
Failure to Assess and Manage G-tube Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to adhere to standards of practice regarding the management of a resident's gastrostomy tube (G-tube) following the resident's readmission from the emergency room (ER). The resident, who had a history of abnormal weight loss and required enteral feeding, had their G-tube replaced in the ER after pulling it out. However, upon the resident's return to the facility, the staff did not assess the G-tube site or verify the type of tube inserted, leading to a misunderstanding that the resident had a urinary catheter instead of a G-tube. Consequently, the facility held the resident's feedings and water flushes for 11 days without a physician's order. The facility's documentation and communication were inadequate, as evidenced by the lack of physician notification regarding the holding of the resident's feedings and flushes until 12 days after the resident's return. The Director of Nursing (DON) relied on reports from ER nurses and did not personally verify the type of tube or review the ER discharge paperwork. This oversight resulted in missed opportunities for feeding and flushing the G-tube, as well as a failure to conduct necessary assessments and document the resident's weights as per physician orders. Interviews with facility staff, including the DON and the physician, revealed a breakdown in communication and responsibility. The DON admitted to not verifying the tube type or reviewing the discharge paperwork, while the physician was not informed of the situation until much later. The resident, who was able to eat orally, did not suffer immediate harm, but the potential for adverse outcomes was present due to the facility's failure to follow proper procedures and ensure the resident's nutritional needs were met.
Failure to Document and Monitor Dialysis Care
Penalty
Summary
The facility failed to provide adequate documentation and monitoring for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease (ESRD), did not have physician orders for dialysis, nor were there orders to assess the dialysis site and dressing or to take vital signs and weights before and after dialysis. The resident's care plan included interventions for assessing weight and vital signs before and after dialysis but did not address monitoring the dialysis port dressing/site. The facility's policy required monitoring of the dialysis resident's status before, during, and after treatments, but this was not consistently followed. Interviews with the resident and staff revealed that the facility used a Dialysis Communication form to document vital signs, weight, and changes before and after dialysis. However, there were multiple instances where vital signs, weights, and assessments of the dialysis site/dressing were not documented. The Director of Nursing (DON) and the Administrator acknowledged the use of the form and the responsibility of the receiving nurse to complete it upon the resident's return from dialysis. Despite this, the documentation was incomplete, indicating a failure to adhere to the facility's policy and ensure proper monitoring of the resident's dialysis care.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to adhere to the regulatory requirement of limiting the use of PRN orders for psychotropic medications to 14 days for three residents. Resident #9 had a diagnosis of restlessness, agitation, and insomnia, with PRN orders for lorazepam without a 14-day stop date. The pharmacy's Medication Record Reviews (MRR) requested a 14-day stop date, but the physician did not address this need. Similarly, Resident #17, diagnosed with COPD, major depressive disorder, and anxiety disorder, had a PRN lorazepam order without a 14-day stop date, despite the pharmacy's request for one. The physician again did not address the need for a stop date. Resident #30, diagnosed with an anxiety disorder, had a PRN order for hydroxyzine without a 14-day stop date. The pharmacy's Gradual Dose Reduction (GDR) request indicated the need for a stop date, but the physician did not address it. The Director of Nursing (DON) acknowledged responsibility for GDRs and MRRs but had not completed the reviews for November and December due to being occupied with floor duties. The facility also failed to provide a policy for the 14-day stop date on PRN psychotropic medications.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically insulin pens, and did not maintain secure medication carts. During observations, it was noted that the medication cart was left unlocked and unattended multiple times, contrary to the facility's policy that requires medication compartments to be locked when not in use. Additionally, several insulin pens, including lispro, Lantus, and Admelog, were found opened and undated, with one Admelog pen being six days past its 28-day shelf life. This indicates a failure to adhere to the manufacturer's recommendations for insulin storage and usage. Interviews with staff, including a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Administrator, confirmed that the medication carts should always be locked when unattended, and insulin pens should be dated upon opening and discarded after 28 days. The facility's policy on medication storage was not followed, and there was no specific policy provided regarding the dating of insulin pens. This deficiency had the potential to affect all residents in the facility, which had a census of 47 at the time of the survey.
Facility Assessment Not Updated Annually
Penalty
Summary
The facility failed to update its facility-wide assessment at least annually, as required by its policy. The assessment, dated 08/07/24, did not accurately reflect the current resident profile and needs. Specifically, it did not account for a resident with a feeding tube, despite the facility having such a resident for multiple years. Additionally, the assessment inaccurately reported the number of residents with intellectual and/or developmental disabilities and based the average care required for Activities of Daily Living (ADLs) on an incorrect census of 20 residents instead of the actual 40 residents. During an interview, the Administrator acknowledged that the facility assessment should have included the resident with a feeding tube and that the average care required for ADLs should have been based on the correct census. The facility's failure to update the assessment meant that the necessary resources, including staffing, equipment, and competencies, were not accurately identified to meet the residents' needs. This oversight indicates a deficiency in maintaining an up-to-date and comprehensive facility assessment to ensure competent care for residents during both day-to-day operations and emergencies.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during several routine care activities, including meal pass, incontinent care, and medication administration. During the hall tray meal pass, a CNA did not wear gloves or perform hand hygiene while handling meal trays and interacting with residents and their personal items. This lack of hand hygiene was observed consistently across multiple rooms, as the CNA touched various surfaces and resident items without sanitizing hands between tasks. In the case of incontinent care for two residents, CNAs failed to perform adequate hand hygiene and glove changes during the process. For one resident, the CNA did not clean all necessary areas during care and continued to handle items and assist the resident without changing gloves or sanitizing hands. Similarly, another CNA did not change gloves or perform hand hygiene between cleaning different areas of the resident's body, which is against the facility's expected procedures. Additionally, during medication administration for two residents, a CMT was observed handling medications with bare hands, transferring them from bubble packs and bottle lids directly into medication cups. This practice was acknowledged by the DON and Administrator as inappropriate, as staff should not touch medications with bare hands. Furthermore, the facility failed to correctly screen five residents for tuberculosis as required by state regulations, with missing or incomplete TB screenings noted in their medical records.
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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