Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Athene Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident’s personal debit card was used without authorization to make multiple ATM withdrawals at a casino, totaling nearly $2,000. Bank records, transaction reports, and casino surveillance linked a housekeeping supervisor and a CNA to the withdrawals and attempted withdrawals. Police interviews documented that the CNA admitted being at the casino with the supervisor, retrieving a bank card from a car, and using a PIN provided by the supervisor, while the supervisor denied making or witnessing ATM withdrawals despite video and photo evidence placing both staff at the casino during the fraudulent transactions.
The facility failed to obtain and administer ordered medications for two residents, resulting in repeated missed doses documented on the MARs. One resident with schizophrenia and other psychiatric diagnoses had an order for daily cariprazine, but staff repeatedly documented the drug as on order or unavailable over an extended period, with no evidence of administration and no documented physician notification, while behavioral issues and a resident‑to‑resident altercation were recorded. A pharmacy representative later reported that no prescription for this medication was sent by the facility during the relevant time. Another resident with alcoholic cirrhosis and hepatic encephalopathy had an order for rifaximin twice daily for 14 days, but it was not documented as given; the pharmacy did not dispense it due to a high out‑of‑pocket cost, and although an NP was told it was not covered and stated it still needed to be dispensed, the NP was not informed that the medication was never administered, and the administrator was unaware of the omission.
Surveyors found that the facility did not post the Missouri DHSS Elder Abuse and Neglect Hotline number or State Long-Term Care Ombudsman contact information in visible locations throughout multiple units, including elevators, Terrace 2 and 3, 3 Short, 3 Long, and the Loop. Instead, only corporate compliance and administrator contact information were prominently displayed, while the Ombudsman number appeared only on a very small label on a Resident Rights poster outside the Social Worker’s office, and no DHSS hotline number was observed there. During a resident council meeting, eight residents reported they were not aware of the Ombudsman program and confirmed that information about it was not posted. The Administrator stated he believed hotline signs should be present in a few specific areas and expected the Ombudsman print to be large enough for residents to see, but survey observations did not confirm adequate, visible posting facility-wide.
Surveyors found that the facility failed to maintain clean, homelike conditions in multiple resident rooms and common areas. Two residents with conditions including osteomyelitis, cellulitis, and lymphedema had visibly soiled bed linens, accumulated trash, used towels and washcloths left on floors, and personal clothing stored in trash bags, with one resident’s IV pole covered in thick, dried residue. Staff interviews revealed inconsistent practices and understanding of responsibilities for changing linens and removing soiled items. On a resident unit, shower rooms contained wet and stained linens left over multiple days, a fire extinguisher cabinet and nearby artwork had large unidentified stains, and an elevator and adjacent walls had sticky floors and splatter. The dining room had cracked and broken windows, one partially covered with cardboard, and a loose handrail was observed near a room. Another room’s floor remained dirty with trash and dust-like splatter over several days, and the main loop hallway had strong odors of urine, sweat, and bowel movement, sticky floors, visible trash, and bags of soiled linens and incontinence products left on the ground, while housekeeping leadership noted that the hallway cleaning machine was broken.
The facility failed to provide consistent ADL care, including bathing, grooming, oral care, shaving, and nail care, to multiple dependent residents as required by their assessments and care plans. Several cognitively intact residents reported not receiving showers for extended periods despite being scheduled for twice-weekly showers, and were observed with oily hair, body odor, and unkempt appearance, while documentation either showed showers as completed or contained long gaps with no entries and no recorded refusals. Other residents with dementia, cirrhosis, Parkinson’s disease, ALS, and hospice status were repeatedly observed with long, dirty fingernails, unshaven faces, oily skin, dry, itchy skin, and teeth coated with debris, even though they were fully dependent on staff for ADLs. Staff interviews revealed that heavy care assignments sometimes led to showers not being done, that there was confusion over whether CNAs, nurses, or social services were responsible for nail care and hair appointments, and that refusals and missed showers were not consistently documented as required by facility policy.
The facility failed to follow physician orders and professional standards for wound care and lab services. A resident with a recent toe amputation had no wound dressing orders in place, and an LPN changed the dressing only when the resident requested it, contrary to policy requiring prompt physician orders and scheduled wound care. Another resident with cellulitis and lymphedema had a leg dressing ordered to be changed on a set schedule and PRN when saturated or dislodged, yet observations showed a saturated, partially detached dressing over multiple days with no documented scheduled or PRN changes. A third resident with multiple comorbidities had STAT UA orders on two days that were not carried out, despite reporting urinary pain and abdominal discomfort; staff acknowledged the urine was simply not obtained and did not implement measures such as straight catheterization that they stated would normally accompany a STAT UA order.
The facility failed to ensure that residents with indwelling urinary catheters had corresponding physician orders for catheter care, as required by its catheter care policy. One resident with neurogenic bladder, bilateral lower extremity impairment, and a Foley catheter had prior catheter care and catheter-change orders discontinued, while the care plan still directed catheter care every shift; updated catheter care orders were not present until later. Another resident with BPH and lower urinary tract symptoms had a care plan calling for catheter care every shift, but no catheter care orders appeared on the physician order sheets during the reviewed period. Staff, including an RN and the DON, acknowledged that all residents with catheters were expected to have catheter care orders in place on admission.
Dignity and Shower Access Failures: A resident was found on the floor and a housekeeper did not report it, another resident was left exposed in a hallway with the brief undone, and a resident with hemiplegia/hemiparesis reported limited access to showers because the men’s and women’s shower rooms on the unit were marked out of service despite conflicting staff reports about their status. The resident became agitated after requesting a shower, and staff acknowledged residents should be covered in public areas.
Delayed Resident Mail Delivery: Residents reported mail was not being delivered timely and was sometimes held in the activities area before distribution. Staff stated mail was delivered at the end of the day, weekend mail was not sorted until Monday, and observations showed multiple stacks of undelivered envelopes with visible postmarks, including time-sensitive items and a birthday card that arrived nearly a month late.
Advance directive and code status documentation was not consistently documented, updated, or reviewed for multiple residents. Some residents had full code or DNR forms that were outdated or missing, while others had conflicting information between the EMR, physician orders, care plans, and the code status book. Staff and leadership stated code status should be checked in the EMR, reflected in care plans, and updated when there is a change in condition or on a yearly basis.
Resident-centered activities were not implemented for two residents with impaired cognition and documented interests, and a third resident who had severe cognitive impairment, anxiety, and behaviors was not placed on one-to-one activities. Residents on The Loop reported too few activities, observations showed no activities in progress at multiple times, the activity calendar did not identify locations, and staff described activities as inconsistent and not meaningful. The Activities Director had not assessed the resident who needed one-to-one support, and the resident remained in bed in a dark room wearing a hospital gown while yelling loudly.
Failure to provide foot care and podiatry referral for four residents. Four residents with varying levels of cognitive and physical impairment had dry, peeling feet and thick, overgrown toenails, yet were not on the podiatry list. One resident was diabetic and tearful about the condition of the toenails, another said he/she was embarrassed and wanted foot care, and staff stated residents needing podiatry should be placed on the list while nurses normally did not trim toenails.
The facility failed to ensure its QAA/QAPI committee developed and implemented an appropriate plan of action for identified quality deficiencies. The Administrator and DON said they used metrics to review concerns, but issues such as timely labs, medication re-ordering, showers, resident weights, and antibiotic-related concerns were not identified in QAPI meetings. Showers were handled through resident council or grievances, and the DON noted she had identified medication documentation concerns in her own audit, but these issues were not reflected in QAPI.
Antibiotic Orders Lacked Indications and Stop Date: The facility failed to follow its infection control policy for three residents receiving antibiotics. Two residents had antibiotic orders that did not include an indication for use, and one resident’s doxycycline order for a UTI had no stop date and continued to be administered across multiple MARs. Staff interviews confirmed that antibiotic orders should include an adequate indication and an end date, but the IP and RN consultant were unaware of residents receiving long-term antibiotics.
Staff allowed a resident to keep and self-administer three prescribed ophthalmic medications at the bedside without following facility policy requiring an interdisciplinary self-administration assessment and a physician order authorizing self-administration and bedside storage. Record review showed active orders for Ofloxacin, Ketorolac, and Prednisolone eye drops but no self-administration assessment and no order permitting bedside medications. Surveyors repeatedly observed the eye drop bottles on the bedside table, and the resident reported self-administering the drops. In interviews, an RN and the DON acknowledged that residents must be assessed for safe self-administration and have a corresponding physician order, which had not been completed for this resident.
The facility did not follow its own bed-hold policy requiring written notice at the time of transfer for hospitalization. Record review showed that two residents who were discharged to the hospital did not have completed and signed bed-hold notices in their files, despite the policy requiring written notice specifying the bed-hold duration and return information and retention of a signed copy. In interviews, an LPN explained that the discharging nurse should fully complete the bed-hold form, including who was informed and the reason for discharge, and the Administrator stated he expected the notice to be given, completed, and signed before the resident left, but this did not occur for these transfers.
The facility failed to meet professional standards when staff did not obtain required admission and readmission weights for two residents with diagnoses including moderate protein-calorie malnutrition, despite physician orders and a policy requiring admission and weekly weights for new or returning residents. In addition, a resident receiving hemodialysis, with multiple comorbidities including CKD, heart failure, and diabetes, lacked timely physician orders for dialysis access assessments such as monitoring for bruising, bleeding, infection, and checking for thrill and bruit, even though the care plan called for close monitoring of the access site. The resident reported that staff did not perform post-dialysis assessments or check the access site, and leadership interviews confirmed expectations that such orders and assessments should have been in place.
Surveyors found that staff failed to follow speech therapy swallowing and positioning recommendations and did not provide required supervision during meals for two residents with cognitive impairment and dysphagia‑related needs. One resident, assessed as dependent for eating and requiring 1:1 feeding and near‑constant swallow safety supervision, was repeatedly observed lying prone in bed, self‑feeding regular food and thin liquids without staff present, including during episodes of loud coughing and spitting out food. Another resident, needing partial to moderate assistance with eating and having a posted swallowing strategies sign directing upright positioning, small bites, slow rate, and supervision, was observed slumped in bed, eating with fingers and left alone after only tray setup and container opening. In both cases, facility leadership and therapy staff acknowledged that expectations were for upright positioning and protective oversight during meals, which was not provided as observed.
Care plans for two residents did not reflect accurate, individualized orders. One resident with DM, CKD, heart disease, and HF had conflicting code status information in the chart, with a DNR in the code status book but a full code order and full code care plan entries in the record. Another resident with a G-tube history, sepsis, CHF, and dysphagia was observed receiving pureed meals, but the care plan focused on NPO noncompliance and tube feeding despite active orders for a regular diet with pureed texture and no tube feeding order.
Failure to communicate with a non-English dominant resident in a form and manner the resident could understand. The resident was Cantonese speaking and had diagnoses including altered mental status, malnutrition, DM, and muscle weakness. Staff used hand gestures and brief English during care and medication administration, but no communication board was available and Google Translate was not used. The resident said staff did not use a communication board and could not read the English activity calendar. The care plan did not direct staff on how to communicate with the resident.
Incorrect g-tube flush during med pass. A resident with seizures, brain injury, and dysphagia had a g-tube and orders for multiple meds via tube plus 120 ml water flushes before and after meds. An LPN diluted each med, flushed 120 ml before administration, and then gave 120 ml after each med, while staff later stated the order was confusing and needed clarification.
Failure to Provide Behavioral Health Care and Services: A resident with dementia, intellectual disabilities, schizoaffective disorder, and bipolar disease was repeatedly observed yelling loudly while lying in bed in a hospital gown with the room dark and staff passing by without checking needs. The record showed anxiety and restlessness, but no psych consult or psych visits, and staff documented no behaviors despite ongoing yelling. Interviews confirmed the resident seemed scared and anxious and would have benefited from 1:1 activities, out-of-bed time, and psychiatric review.
Narcotic Medication Not Double-Locked or Counted: A resident with CKD, muscle weakness, and dementia had Tramadol brought from home on admission, but the medication was found in a grocery bag on the nurse's cart and later in the med storage room without a double lock. The narcotic was not listed on the count sheet, and staff said it should have been counted every shift and destroyed or returned when the resident discharged.
A resident with anemia, HF, HTN, renal failure, DM, hyperlipidemia, and dialysis needs was on a therapeutic diet with fluid restriction, but surveyors observed meals that did not match the ordered diet or menu and did not include an appropriate substitute when starches were omitted. The resident reported receiving different foods than other residents and complained about limited choices, while the RD was unsure whether the meals provided enough calories and the DON stated staff should ensure appropriate substitutes when starches are declined.
Infection control failures were observed with two residents. A resident with a urinary catheter and diagnoses including a-fib and a history of sepsis had no EBP signage or PPE caddy at the door during care, and staff emptied the catheter without PPE. Another resident with osteomyelitis of the left ankle and foot had wound care performed using blue-handled scissors that were not disinfected with the facility’s germicidal wipes; instead, the scissors were cleaned with hand sanitizer and wound cleaner before the dressing was cut.
Two residents who required staff assistance for bathing and personal hygiene did not receive scheduled showers due to ongoing shortages of towels and washcloths. Staff across multiple units reported that linen carts and closets were often empty during morning care, leading to delays or missed hygiene care. Despite recent linen purchases and new equipment, inconsistent restocking and limited access to laundry supplies continued to impact residents' ability to receive timely personal care.
Staff did not consistently use required gowns and gloves during high-contact care activities for two residents with wounds and indwelling catheters, despite clear orders and signage. Catheter drainage bags were observed lying on the floor and not placed in privacy bags as required, and staff showed inconsistent understanding of proper procedures. Additionally, a dietary aide transported uncovered plated food on a cart, contrary to facility expectations for food safety.
Staff failed to consistently document and administer tube feedings for a resident with a g-tube, leaving multiple entries blank and lacking explanations for missed administrations or refusals. Additionally, Hydrochlorothiazide was administered to another resident without documenting required blood pressure readings beforehand, despite physician orders and facility policy. Leadership interviews confirmed that documentation and monitoring expectations were not met.
Staff failed to timely transcribe new treatment orders and accurately document wound care for several residents with complex wounds, including pressure ulcers and deep tissue injuries. In multiple cases, wound treatments were not started promptly, documentation was incomplete or missing, and physician orders for devices such as wound vacs were not obtained. These deficiencies were confirmed through record review, observation, and staff interviews.
A resident with severe protein-calorie malnutrition did not have admission and weekly weights obtained as ordered, despite facility policy and clear risk factors. Staff failed to document reasons for missed weights or make further attempts to obtain them, and there was no evidence of consistent monitoring or notification of significant weight changes. This resulted in inadequate oversight of the resident's nutritional status.
A resident with vascular dementia and behavioral disturbances did not receive necessary behavioral health care due to the facility's failure to accurately document behaviors and administer psychotropic medications as ordered. Staff often recorded no behaviors despite reports of aggression, non-compliance, and refusals, and medication records did not match pharmacy deliveries or actual administration. The facility did not follow its own policies for behavior management and medication documentation, resulting in inadequate care.
A resident with dementia and agitation was physically abused by a CMT following a verbal altercation, resulting in visible injuries. Staff accounts conflicted, with some initially reporting the resident as the aggressor, but later statements and interviews indicated the CMT struck the resident multiple times. The facility did not immediately recognize or investigate the incident as abuse, and the resident's allegations and injuries were not promptly addressed according to policy.
A resident sustained scratches to the neck and hand following an altercation with multiple staff members. The facility failed to conduct a thorough investigation, as required by policy, after a CNA reported that a staff member had assaulted the resident. The DON did not interview the resident or staff privately, did not report the new allegation to the Administrator, and did not ensure proper documentation or reporting to authorities. Staff statements were collected in a manner that compromised their reliability, and at least one staff member reported feeling coerced into providing a false account.
A resident with a seizure disorder and complex medical history did not receive nine out of ten prescribed doses of anti-seizure medication due to unavailability, and staff failed to notify the DON or physician or use the e-kit supply as required by facility policy. The resident and family repeatedly requested the medication, but it was not provided until several days later, with no clear communication or timely intervention from staff.
The facility failed to ensure residents were free from significant medication errors, including entering and administering a lower dose of Depakote than ordered for a resident after hospital admission, and crushing delayed release Depakote tablets for two residents against manufacturer and pharmacy recommendations. One resident was hospitalized with a low therapeutic level of the medication, and staff interviews confirmed that proper procedures and policies were not followed.
A CNA used profanity while on a personal cell phone during feeding assistance to a resident with severe cognitive impairment, violating the resident's dignity. Four other residents reported staff frequently using phones during care, which they found disrespectful. Facility staff confirmed that personal cell phone use during care is against policy, and recent training on this issue was not attended by the CNA involved.
The facility failed to maintain food temperatures at a safe level, with several residents reporting cold meals. Observations showed that the tray cart was not consistently plugged in, leading to food temperatures below the required 120 degrees Fahrenheit. Staff interviews revealed a lack of communication and training on maintaining food temperatures during meal service.
The facility failed to date opened food packages and maintain cleanliness in dining areas and kitchen equipment. Observations revealed undated food items, dead roaches in dining areas, and unclean steam table wells. Staff interviews indicated a lack of adherence to cleaning protocols and food labeling responsibilities.
The facility failed to maintain safe and appetizing food temperatures, with hot food items not reaching the required 135°F. Observations showed significantly lower temperatures for various food items, and no temperatures were logged for a lunch meal. Residents expressed dissatisfaction with food temperatures, and the Dietary Manager and Administrator acknowledged the issue, noting outdated equipment and the need for regulatory compliance.
A resident with diabetes and other health conditions did not receive prescribed medications, Farxiga and Trulicity, for several days due to communication failures between the facility staff and the pharmacy. The DON acknowledged the oversight, noting that the pharmacy required approval for the medications, which was delayed, and the nurses failed to notify the pharmacy or the DON about the unavailability of the medication.
A resident with severe cognitive impairment and a history of aggressive behavior physically assaulted other residents, leading to a deficiency in protecting residents from abuse. Despite having a care plan for behavior management, the facility failed to implement effective interventions, resulting in harm to other residents. Staff interviews indicated challenges in managing the resident's unpredictable aggression, especially with limited staffing.
A facility failed to timely complete pre-admission screenings and incorporate PASARR Level II recommendations into a resident's care plan. The resident, with a history of schizophrenia and other conditions, was admitted without necessary evaluations. The care plan lacked a behavioral support plan and did not address socialization needs, leading to management challenges due to the resident's history of incarceration and trauma.
A facility failed to provide necessary behavioral health care services for a resident with a history of schizophrenia and psychosis, leading to multiple incidents of verbal and physical aggression. Staff were not informed on how to handle the resident's escalating behaviors, and the care plan lacked detailed interventions. Interviews revealed staff were not given instructions on managing the resident's behaviors, contributing to the facility's failure to meet the resident's psychosocial needs.
A resident's credit card was misappropriated by two CNAs who used it to purchase food from a local restaurant. The incident occurred after the resident's adult child, also a resident, accidentally left the card at a vending machine. The facility's investigation confirmed the unauthorized use, leading to the termination of the involved CNAs.
Misappropriation of Resident Funds by Facility Staff at Casino
Penalty
Summary
The deficiency involves the misappropriation of a resident’s personal funds by facility staff. Record review of the resident’s personal bank statement for November 2025 showed multiple withdrawals using the resident’s debit card at River City Casino, totaling $1,927.00, with individual withdrawals of $1,009.00, $709.00, and $209.00. A transactions report from the bank, obtained by the Town and Country Police Department, documented ATM withdrawals and attempted withdrawals at the casino using the resident’s debit card, including a transaction that exceeded the card limit. Still photos and video from the casino, provided to the police, showed the Housekeeping Supervisor and a CNA entering the casino, walking to a car, and later driving away around the time of the fraudulent ATM transactions. Police investigative reports and interviews further linked the staff members to the use of the resident’s debit card. In a police interview, the CNA confirmed that the driver’s license photo used at the casino blackjack table was his/hers and acknowledged being at the casino with the Housekeeping Supervisor. The CNA stated that the Housekeeping Supervisor asked him/her to retrieve a Capital One card from the car and withdraw $1,000, and that the Housekeeping Supervisor later went to the ATM and withdrew more money. The CNA reported that the Housekeeping Supervisor became stressed afterward and said he/she needed to put money back into his/her mother’s account, and that the Housekeeping Supervisor provided the PIN for the card to the CNA. The CNA identified both him/herself and the Housekeeping Supervisor in the still photos from the casino video footage. In contrast, during an internal interview with the Administrator, the Housekeeping Supervisor denied taking money out of the ATM or seeing the CNA take money out, despite the external evidence placing both staff at the casino during the time of the unauthorized withdrawals from the resident’s account.
Failure to Obtain and Administer Ordered Medications for Two Residents
Penalty
Summary
The facility failed to ensure timely receipt and administration of physician-ordered medications, resulting in multiple missed doses for two residents. For one resident with diagnoses including lung disease, schizophrenia, anxiety, bipolar disorder, insomnia, and depression, the physician ordered cariprazine 4.5 mg once daily upon the resident’s readmission. The order was verified and faxed to the pharmacy, and the medication appeared on the MAR; however, documentation throughout late January and February repeatedly showed the drug as “on order” or “unavailable,” with no evidence that the medication was actually administered. The January MAR reflected 7 of 7 missed administration opportunities, and the February MAR showed 24 of 28 missed administration opportunities for cariprazine. Progress notes for this resident documented behavioral issues during the same period, including difficulty sleeping, frequent use of the call light, yelling that disturbed other residents, inability to be easily redirected, and a resident-to-resident altercation that led to psychology and psychiatry consults. Despite the ongoing unavailability of the antipsychotic medication, there were no documented notifications to the physician regarding the missed doses. A pharmacy representative later stated that the pharmacy had not received a prescription for cariprazine from the facility in January following the resident’s readmission and that the next documented dispensing of the medication did not occur until March, when a 14‑day supply was sent. For a second resident with alcoholic cirrhosis and hepatic encephalopathy, the MAR contained an order for rifaximin 550 mg twice daily for 14 days, but there was no documentation that the medication was administered for the entire ordered period. The pharmacy representative reported that rifaximin was not sent because it required a $1600 out‑of‑pocket payment and was not covered by the resident’s health plan, and that payment from either the facility or the resident was needed. A nurse practitioner stated that nursing staff had informed them that the medication was not covered and asked about a less expensive alternative; the nurse practitioner responded that the rifaximin needed to be dispensed and was not informed that the medication was not being administered. The administrator later stated he was unaware the resident had not received rifaximin and that, in general, staff were expected to notify leadership about missing medications rather than continue to document non‑administration.
Failure to Post DHSS Abuse Hotline and Ombudsman Contact Information in Visible Locations
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to post required contact information for the Missouri Department of Health and Senior Services (DHSS) Elder Abuse and Neglect Hotline and the State Long-Term Care Ombudsman program in visible locations. During observations conducted over multiple days, surveyors noted that no DHSS Abuse and Neglect hotline numbers or Ombudsman contact information were posted in the elevators, on Terrace 2, on the middle hall double doors of Terrace 3, on 3 Short, on 3 Long, or on the Loop. Instead, only corporate compliance contact information was posted in several of these areas. In the front lobby, a bulletin board sign instructed individuals who suspected abuse or neglect to contact the Administrator and listed the Administrator’s phone number, but did not include the DHSS hotline. Outside the Social Worker’s office, a Resident Rights poster included the Ombudsman’s contact number only on a small label approximately 1 inch by 2 5/8 inches, and there was no DHSS hotline number observed there. During a resident council meeting interview, all eight residents present stated they were not aware of the Ombudsman program and confirmed that information about the program was not posted. One resident asked for the correct spelling of the advocacy agency, further indicating unfamiliarity. In a subsequent interview, the Administrator reported that there should be signs for the hotline number by the business office, by the stairwell near Terrace 2, and near the bird cages, but he was only aware of those locations and could not confirm broader posting. He also stated he would need to see the print used for the Ombudsman contact number but would expect it to be large enough for residents to see. These observations and interviews showed that the facility did not adequately post the required State agency and advocacy group contact information, including the DHSS Elder Abuse and Neglect Hotline and Ombudsman program details, in a manner visible and accessible to residents.
Failure to Maintain Clean, Homelike Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and homelike environment in resident rooms and common areas, as required by its own policies. For one resident with osteomyelitis, muscle weakness, unsteady gait, and a need for assistance with personal care, surveyors repeatedly observed an IV pole with thick, crusted yellow dried liquid on the bottom and wheel coverings over several days. The same resident’s fitted bed sheet had maroon and dark brown stains and smears, crumbs were present along the baseboards and behind the dresser, and the resident’s clothing was stored in a clear trash bag. The resident reported that the sheets had never been changed since admission and described the room as filthy, stating the crusted liquid had been on the IV pole since it was brought into the room. Another resident, admitted with cellulitis of the left lower limb and lymphedema, was found over multiple days to have used, stained towels in the corner of the room and used washcloths and towels on the bathroom floor. A grocery bag full of trash was tied to the nightstand, and the fitted bed sheet had brown smears and yellow stains. This resident stated that sheets had never been changed since admission, that staff said they would change the sheets but did not follow through, and that towels in the room had been left by the Wound Nurse the prior week. The resident indicated a desire to clean the room personally but was unable to do so. Staff interviews showed inconsistent understanding of responsibilities: CNAs reported sheets were changed on shower days and clothing should be in closets, while housekeeping staff stated nursing changed sheets and that towels and trash should be removed during room cleaning, with medical equipment cleaning referred to supervisors. Additional observations documented unclean and poorly maintained common areas and equipment. On the 3rd floor terrace, the fire extinguisher cabinet had a large, unidentifiable white stain on multiple dates, and shower rooms contained wet towels on the floor and stained washcloths left in sinks and stalls over repeated observations. The elevator floor had dark, sticky stains on several days, with residents’ and staff’s shoes audibly sticking, and nearby walls and artwork had unidentifiable red splatter and large white stains. The 3rd floor dining room had multiple cracked or broken double windows, some unable to close fully, and one window partially covered by a large piece of cardboard; a handrail outside a resident room was loose and moved when touched. A resident room was repeatedly observed with dirty floors, trash wrappers, and a large dust-like splatter in the bathroom. The loop main hallway was repeatedly noted to have strong odors of urine, sweat, and bowel movement, sticky floors, visible trash, an open dirty linen cart emitting odor, and bags of visibly soiled linens and incontinence products on the ground. The Director of Housekeeping stated housekeepers were responsible for resident rooms and floor technicians for hallways and room floors, and acknowledged the hallway cleaning machine was broken, while the Administrator and DON stated their expectation that rooms, hallways, linens, and equipment be clean and properly stored.
Failure to Provide Consistent Bathing, Hygiene, and Nail Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate activities of daily living (ADL) care, including bathing, personal hygiene, oral care, shaving, and nail care, as required by residents’ assessed needs and facility policy. The facility’s ADL policy required that residents’ abilities in ADLs not deteriorate unless decline was unavoidable, and that residents unable to carry out ADLs receive necessary services to maintain grooming and personal and oral hygiene. Multiple cognitively intact residents reported not receiving showers or adequate hygiene despite documentation indicating showers or baths were provided, and there was no documentation of refusals or unavoidable reasons for missed care. Staff interviews revealed inconsistent understanding of responsibilities for nail care and grooming, and acknowledgment that heavy care assignments sometimes resulted in showers not being completed. One resident with osteomyelitis, diabetes, and a PICC line was documented as having received several showers, yet was observed with long facial hair, odor, and reported never having had a shower because staff would not remove a foot dressing or cover the PICC line. Another resident with ALS, muscle wasting, dysphagia, and full dependence for ADLs was scheduled for showers twice weekly but reported not having had a shower for the entire month, feeling dirty, and wanting hair washed; staff confirmed that heavy care on the hall sometimes led to showers not being done. A resident with a gastrostomy and history of sepsis, dependent for bathing, had long gaps of 6–18 days without documented showers or baths, appeared with oily skin and disheveled hair, and stated they had not received a shower in weeks and were told equipment was not working or lifts were not charged, while staff were unaware of any non-functioning lifts and there was no documentation of refusals. Additional residents with ADL self-care deficits and dependence on staff also lacked appropriate bathing and hygiene. One resident with cirrhosis and encephalopathy reported never receiving a shower or hair wash since admission, only wipe-downs, and remained with very dry skin and oily, stringy hair; staff later stated a shower chair was available on another floor despite the resident being told none was available. Another resident with dementia, stroke, and on hospice care was documented by hospice as receiving bed baths, yet was repeatedly observed with an unshaven face, long fingernails with dark matter underneath, oily face, and white flakes in neck folds, and later only partially shaved with nails still long and dirty. A newly admitted resident with severe cognitive impairment and dependence for bathing and oral hygiene had no January shower documentation and was observed with teeth caked with yellow matter and fingernails with brown matter underneath. The deficiency also included failures in nail and grooming care for several residents who required staff assistance. One resident with Alzheimer’s disease, chronic kidney disease, depression, and Parkinson’s disease, who required moderate assistance for personal hygiene, was repeatedly observed with long, jagged fingernails and requested nail care, while a CNA stated nurses were responsible for trimming nails and was unsure where to find nail files. Another resident with Alzheimer’s disease and muscle weakness, dependent on staff for hygiene, was observed multiple times with long, jagged nails and matter underneath, with staff indicating that either the nurse or hospice nurse could trim nails. A resident with Parkinson’s disease and severe cognitive impairment, fully dependent on staff, was observed on multiple days with long, oily hair, an unkempt beard, and uneven, dirty nails. Interviews with CNAs, nurses, the regional nurse, DON, and administrator showed conflicting statements about who was responsible for hair appointments and nail trimming, and confirmed expectations that residents receive showers or bed baths at least twice weekly and that refusals be documented, which did not consistently occur. Overall, the survey findings showed that despite policies and care plans requiring regular bathing, grooming, and nail care, multiple residents did not receive showers, bed baths, shaving, or nail care as needed or requested, and documentation did not support refusals or unavoidable reasons for missed care. Residents reported feeling dirty, embarrassed, or forgotten, and observations repeatedly showed oily hair, unshaven faces, long and dirty fingernails, and inadequate oral hygiene. Staff acknowledged workload issues and demonstrated inconsistent understanding of roles and documentation requirements, contributing to the failure to ensure residents received appropriate ADL care in accordance with their needs and the facility’s own policy.
Failure to Follow Wound Care and Laboratory Orders per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional standards, and facility policies for wound care and laboratory services. One resident with peripheral vascular disease and diabetes, who had all toes amputated on the left foot due to osteomyelitis, had no physician orders for left foot wound dressing changes from admission through early January. The resident reported always having to ask staff to change the dressing. An LPN confirmed there were no wound care orders and stated that dressing changes were done only when the resident requested them. The facility’s wound policy required obtaining treatment orders in the absence of existing orders and providing wound care per physician orders, but this was not followed for this resident’s post‑amputation foot wound. Another resident with cellulitis of the left lower limb and lymphedema had a physician order for left calf wound care specifying cleansing, application of methylene blue foam, abdominal pads, gauze wrap, and tape, to be changed three times weekly and PRN if saturated, soiled, or dislodged. Record review showed a scheduled dressing change was not documented as completed on a specific date, and no PRN dressing changes were documented over several days. On two separate observations, the resident was seen with an undated left leg dressing that was saturated with serous drainage and with the wrap falling off, requiring the resident to place absorbent materials (a bed pad, then a pillowcase) under the foot to contain the drainage. Interviews with nursing staff and a wound physician confirmed the expectation that dressings be changed as ordered and when wet or dislodged, which did not occur in this case. A third resident, cognitively intact with multiple comorbidities including renal failure, diabetes, and hyponatremia, had STAT orders for a UA with reflex to culture on two consecutive days, but the urine specimen was not obtained as ordered. The resident reported pain with urination and lower abdominal pain, stated they had not completed a urine test, and had not urinated on one of the observation days. An LPN acknowledged that urine had not been obtained and that the resident was not refusing. Subsequent orders for laboratory tests, including urine culture, were entered, and staff reported they were in the process of collecting labs and that normally a STAT UA should include straight catheterization if needed, which had not been done. Documentation later showed the UA was eventually completed days after the initial STAT orders, and interviews with nursing leadership indicated they were unaware of the missed and delayed UA and related hydration issues, despite facility policy requiring timely provision and follow‑up of ordered laboratory services. Overall, the facility did not follow its own Wound Treatment Management and Laboratory Services and Reporting policies, as residents did not receive wound care and laboratory testing in accordance with physician orders, professional standards, and stated expectations for timely treatment and documentation.
Lack of Physician Orders for Catheter Care for Residents With Indwelling Urinary Catheters
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents with indwelling urinary catheters had physician orders that included catheter care instructions, as required by facility policy. The catheter care policy, revised 8/1/25, stated that residents with indwelling catheters would receive catheter care every shift and as needed, drainage bags would be emptied when half-full or every three to six hours, and drainage bags would be kept below bladder level. For one resident with mild cognitive impairment, high blood pressure, kidney failure, neurogenic bladder, bilateral lower extremity impairment, and use of a wheelchair, the electronic physician orders in November 2025 showed discontinuation of orders for monthly Foley catheter and drainage bag changes, catheter care, and catheter privacy covering. The resident’s quarterly MDS still documented an indwelling urinary catheter, and the care plan in use during the survey included a focus on Foley catheter care with an intervention to provide catheter care every shift. Despite the care plan, the resident’s physician orders did not include catheter care until new orders were entered in January 2026 for Foley catheter to gravity drain, catheter care every shift, weekly catheter anchor changes, and use of a leg bag when out of bed. Observations over multiple days showed the resident in an electric wheelchair with the catheter drainage bag hanging from the right armrest. For another resident with a diagnosis including benign prostatic hyperplasia with lower urinary tract symptoms, the care plan identified the presence of a urinary catheter and directed catheter care every shift, but physician order sheets from 12/31/25 through 1/3/26 contained no catheter care orders. In interviews, an RN and the DON stated that all residents with urinary catheters were expected to have catheter care orders in place, and that such orders should be entered on admission, confirming that the absence of these orders for two residents did not meet facility expectations.
Dignity and Shower Access Failures
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner when staff observed a resident on the floor and did not report it, leaving the resident there without notifying nursing staff. Resident #183 was admitted with diagnoses including difficulty swallowing, muscle weakness, diabetes, seizures, and a fall history. During observation, the resident was seen on the floor on his/her buttocks with the wheelchair against his/her back, while a housekeeper was in the bathroom and continued cleaning after being told the resident was on the floor. The housekeeper did not tell anyone about the resident's condition. The facility also failed to maintain resident dignity when Resident #69 was observed in a wheelchair in the hallway wearing a shirt and brief with the brief undone, exposing the resident's genitals in a public area. The resident had diagnoses including Alzheimer's disease, diabetes, heart failure, and muscle weakness, and was dependent on staff for lower-body dressing. Staff interviews confirmed that residents should be clothed or covered in public spaces, and the exposed condition was identified as a dignity concern. In addition, the facility failed to ensure the men’s and women’s shower rooms on 3 Long Unit were in working order and available for resident use for an undetermined period of time. Resident #147, who had hemiplegia and hemiparesis following a stroke and required substantial assistance with bathing, reported not being able to shower on the unit and stated he/she had only one shower in the past five weeks. The shower rooms had taped signs stating they were under construction, and staff gave conflicting information about whether the showers were out of order or functioning. The resident became increasingly agitated and verbally aggressive after requesting a shower and stated he/she believed the facility did not like men and was discriminating against men.
Delayed Resident Mail Delivery
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods by not delivering mail on Saturdays, a regular mail delivery day identified by the United States Postal Service, and by not delivering mail timely. During the resident council interview, eight residents reported that mail was not being delivered timely, that it would sit in the activities room before distribution, and that they had not received mail that week. One resident stated a birthday card arrived nearly one month late after checking the postmark and waiting for it because it contained $25, and the resident was upset about the delay. During interviews and observations, the Director of Activities stated mail was delivered at the end of the day and that reception staff sorted it after the facility received it. Observation showed stacks of envelopes with room numbers written on them, including letters with visible postmarks from 12/30/25 and 1/2/26, and another large stack of mail on a second desk in the office. On 1/13/26, the Director of Activities again had a stack of envelopes on the desk with a postmark dated 1/9/26 and said the mail had come the previous day and would be given to activity aides for delivery. A receptionist stated that on weekends, mail was not sorted because staff did not know how to sort it properly, so it was held until Monday. The Administrator stated he expected mail to be delivered timely and on Saturdays and was not aware staff were waiting until Monday to sort Saturday mail.
Advance Directive and Code Status Documentation Not Kept Current
Penalty
Summary
The facility failed to ensure advance directive and code status forms were documented, updated, and reviewed annually for 7 sampled residents. The deficiency was identified during interview and record review and involved residents whose records showed either missing current signed code status forms or code status documentation that did not match other parts of the medical record, care plan, or code status book. Resident #1 had a request concerning life-prolonging procedures form showing full resuscitation preferences, but the medical record also included a physician order for full code and no updated signed code status election form since 2020. Resident #6 had a code status form showing full resuscitation, a physician order for full code, and a care plan reflecting full code status, but there was no updated and reviewed signed code status form since 2023. Resident #39 had a full resuscitation form and a physician order for full code, but the record contained no current signed code status form. Resident #55 had a DNR form and a physician order for DNR, but there was no signed code status form after the date listed on the form. Resident #176 had a physician order for full code, a hospital discharge summary listing default full code and needing discussion, and a care plan reflecting full code status, but there was no signed code status form. Resident #12’s EMR showed conflicting code status information: the top of the EMR listed full code, there was a physician order for full code, and the care plan showed full code status, but a scanned code status form showed DNR signed by the resident and representative. Resident #17’s EMR showed a scanned DNR code status form and a physician order for DNR, and the care plan showed DNR status, but the 3rd Floor Terrace code status book did not contain a code status for the resident. Staff interviews stated that code status should be checked in the EMR, reviewed in the physical code status book if the system was unavailable, reflected accurately in care plans, and updated when there was a change in condition or annually, with the Administrator and DON stating the code status form should be signed yearly by the resident or responsible party and the physician.
Resident-centered activities were not provided and one resident was not placed on one-to-one activities
Penalty
Summary
The facility failed to implement a resident-centered activities program that incorporated residents’ interests, hobbies, and cultural preferences for two residents on The Loop, and it failed to provide one-to-one activities for a resident who was unable to participate in group activities. The facility’s activities policy stated that residents’ interests and needs would be assessed routinely and that activities would include large and small groups, one-to-one, and self-directed programs designed to meet each resident’s interests and support physical, mental, and psychosocial well-being. One resident had diagnoses including Alzheimer’s disease, chronic kidney disease, major depressive disorder, and Parkinson’s disease, with moderately impaired cognition. During interview, the resident stated there were not enough activities and wanted more to do. Another resident had diagnoses including dementia, major depressive disorder, anxiety, and chronic kidney disease, with moderately impaired cognition. That resident’s care plan identified interests in trivia, bingo, church, and helping out, but during interview the resident stated there were not enough activities and was bored most of the time. Observation on The Loop showed no activities in progress at multiple times on several days, and staff stated there were not enough activities on The Loop and that activity staff did not take residents off the hallway to do activities. The activity calendar listed scheduled programs such as country hits, Bible study, board games, trivia, chair Zumba, happy hour, movies, and worship, but it did not indicate the location of the activities. Staff interviews indicated that activities on The Loop depended on which activity aide came, and the Administrator and DON stated the activities on The Loop needed work and should be meaningful and stimulating. Residents in council also reported that many activities had been reduced, including bingo, happy hour, and other offerings. A third resident had severe cognitive impairment and preferences documented for choosing clothing, listening to music, being around animals and pets, doing things with a group, favorite activities, going outside, and participating in religious services or practices. The resident also had diagnoses including intellectual disabilities, dementia, Parkinson’s disease, schizoaffective disorder, muscle weakness, cognitive communicative deficit, and bipolar disease. Observations showed the resident lying in bed in a dark room, wearing a hospital gown, yelling loudly, with the privacy curtain positioned so the resident could not see into the hall. The resident was not listed on the January one-to-one activities list, the room calendar was outdated, and the Activities Director stated she had never met or assessed the resident. The NP stated the resident would benefit from one-to-one activities due to behaviors and anxiety, and the Administrator and DON stated the resident should have been on one-to-one activities because of yelling out and anxiety.
Failure to Provide Foot Care and Podiatry Referral
Penalty
Summary
The facility failed to ensure appropriate foot care for four sampled residents and failed to ensure they were on the podiatry list as needed. Review of the facility’s ADL policy stated that residents would receive necessary services to maintain grooming and personal hygiene, and that ADL abilities would not deteriorate unless unavoidable. However, review of the podiatrist list dated 1/7/26 showed that Residents #133, #72, #69, and #177 were not listed for podiatry services despite observed foot and nail concerns. Resident #133 was cognitively intact, required maximum assistance with bathing, lower body dressing, personal hygiene, and footwear, and had diagnoses including cirrhosis of the liver, left humerus fracture, and difficulty walking. On observation, both feet were extremely dry and both big toes had chipped nail polish; the toenails on both feet were about half an inch long, thick, and jagged. The resident said he/she was diabetic, normally went to a salon for pedicures, was tearful, and said the toenails looked like eagle talons. Resident #72 required supervision or touching assistance with bathing, lower body dressing, personal hygiene, and footwear, and had diagnoses including cellulitis of the left lower limb and lymphedema. Both feet had gray thick toenails curled under about half an inch, and the resident said he/she was embarrassed and wished to receive foot care. Resident #69 was moderately cognitively impaired and dependent on staff for lower body dressing; both feet had thick yellow toenails and peeled dry skin on the heels and balls of the feet. Resident #177 had severe cognitive impairment and was dependent on staff for bathing, lower body dressing, personal hygiene, and footwear; the resident’s feet were extremely dry, the right heel appeared dry and peeled, and flakes of skin fell off when socks were removed. Staff stated that residents needing podiatry were to be placed on the podiatry list, nurses normally did not trim toenails, and dry skin should be treated.
QAPI Committee Failed to Address Identified Quality Deficiencies
Penalty
Summary
The facility failed to ensure its QAA/QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility’s 2025 QAPI Plan stated that it would identify opportunities for improvement, address gaps in systems or processes, ensure adequate staffing and resources, and conduct performance improvement projects in high-risk and problem-prone areas. However, during an interview, the Administrator and DON said they pull data in metrics to determine areas of concern, and that interventions would be developed for issues such as residents returning to the hospital, meal timeliness, and wounds. They also stated that the facility had not completed its QAPI for December 2025, and until November 2025 had not identified issues with obtaining labs timely. The DON stated that showers were not discussed in QAPI and instead came up in resident council or the grievance process. Residents receiving antibiotics were discussed during clinical or weekly risk meetings, and the clinical team reviewed morning orders to ensure residents with hospital orders were followed. The DON said medication re-ordering and pharmacy issues had not been identified as concerns, although she later said her own audit identified concerns and she completed an in-service on documentation of medication orders, notifying the pharmacy, and documenting in the MAR. Issues with ordering medications for residents re-admitted from the hospital, obtaining resident weights, showers, and antibiotic issues were not identified in QAPI meetings.
Antibiotic Orders Lacked Indications and Stop Date
Penalty
Summary
The facility failed to follow current infection control best practices and its own infection control policy for three of 47 sampled residents who were receiving antibiotic therapy. The deficiency involved antibiotic orders that did not include an adequate indication for use for Residents #69, #166, and #26, and one resident’s antibiotic order also lacked a stop date. The facility’s Antibiotic Stewardship Program Policy required monitoring of antibiotic use, review of antibiotic starts, and random audits of antibiotic prescriptions to verify completeness and appropriateness. Resident #69’s quarterly MDS dated 11/26/25 showed diagnoses including Alzheimer’s disease, diabetes, heart failure, and muscle weakness, with moderately impaired cognition. The POS dated 1/2026 included an order dated 11/22/25 for Gentamicin Sulfate external cream 0.1% to be applied topically at bedtime related to need for assistance with personal care, but the antibiotic medication did not have any indications for use. Resident #166’s quarterly MDS showed diagnoses including dementia, major depressive disorder, anxiety, and chronic kidney disease, with moderately impaired cognition. The POS dated 1/2026 included an order dated 12/9/25 for Cefadroxil 500 mg by mouth two times a day for antibiotic for three months, but the antibiotic medication did not have any indications for use. Resident #26 was re-admitted on 11/15/25 and had a suprapubic catheter related to bladder dysfunction, with diagnoses including ALS, bipolar disease, muscle wasting and atrophy, dysphagia, and bladder dysfunction. The ePOS showed an order dated 11/15/25 for Doxycycline 100 mg twice a day for urinary tract infection, but the order did not include an end or stop date. The MARs for November and December 2025 and January 2026 showed the doxycycline was administered as ordered, and the order still lacked a stop date. During interviews, staff stated antibiotic orders should include a stop/end date and an adequate indication for use, and the facility IP and RN consultant were unaware of any residents receiving long-term antibiotics at the time of interview.
Unauthorized Self-Administration and Bedside Storage of Ophthalmic Medications
Penalty
Summary
Facility staff failed to follow its policy on resident self-administration of medications by allowing a resident to keep and self-administer multiple ophthalmic medications at the bedside without the required assessment or physician order. The facility’s policy, revised 8/1/25, states that residents may only self-administer medications after an interdisciplinary team determines which medications can be safely self-administered, with consideration of the resident’s physical and cognitive abilities, understanding of medication instructions, and ability to store medications safely. The policy also requires documentation of the self-administration assessment in the medical record, a physician order authorizing self-administration and bedside storage, and staff reporting of any unauthorized medications found at the bedside. Record review for one resident showed active physician orders for Ofloxacin 0.3% ophthalmic solution, Ketorolac Tromethamine 0.5% solution, and Prednisolone acetate 1% ophthalmic suspension, each ordered four times daily for cataract-related treatment, but no orders authorizing self-administration or bedside storage of these eye drops and no completed self-administration assessment in the medical record. On multiple observations, surveyors saw three eye drop bottles (Ofloxacin, Ketorolac, and Prednisolone) on the resident’s bedside table, and the resident stated that they administered the eye medications themself. In interviews, an RN and the DON confirmed that facility practice requires a management-conducted self-administration assessment and a physician order permitting self-administration and bedside storage, which were not present for this resident.
Failure to Provide Required Bed-Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notices to residents or their representatives at the time of transfer for hospitalization, as required by its Bed Hold Notice Upon Transfer policy dated 8/1/25. The policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would give written notice specifying the duration of the bed-hold policy and information about return to the next available bed, and that a signed and dated copy of this notice would be kept in the resident’s file. Record review for Resident #166 showed a discharge to the hospital on [DATE] with no completed and signed bed-hold notice for 10/16/25. Record review for Resident #177 showed a discharge to the hospital on [DATE] with no completed and signed bed-hold notice for 12/22/25. During interview, LPN K stated that the discharging nurse should document on the bed-hold form whom they spoke with regarding the resident’s discharge and the bed-hold policy, and that the reason for discharge and all sections of the form should be completed. In a separate interview, the Administrator stated he would expect bed-hold notices to be given to the resident or resident representative before the resident leaves the facility and that the form should be filled out and signed. Despite these expectations and the written policy, the records for the two hospitalized residents lacked the required completed and signed bed-hold notices.
Failure to Obtain Ordered Weights and Dialysis Access Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards by not obtaining ordered weights for two residents and not securing timely physician orders for hemodialysis assessments for another resident. For one resident admitted with diagnoses including moderate protein calorie malnutrition, dementia, seizures, and muscle weakness, the physician ordered weekly weights from admission for four weeks, then monthly. The facility’s weight monitoring policy required weights on admission and weekly for four weeks for new admissions. Record review showed weights documented on two dates after admission, but no admission weight was recorded. The resident’s care plan identified a nutritional problem with moderate protein malnutrition and dysphagia and included an intervention to monitor weight as indicated, but the admission weight was missing. For a second resident with an initial admission, subsequent discharge, and readmission, diagnoses included dementia, muscle weakness, intellectual disabilities, schizoaffective disorder, moderate protein calorie malnutrition, dysphagia, and difficulty walking. There was an order for weekly weights from admission for four weeks, then monthly. The care plan identified a nutritional problem with a goal to maintain adequate nutritional status as evidenced by maintaining weight and included providing and serving diet as ordered. Weight records showed values on the initial admission date and subsequent dates, but there was no weight documented at the time of readmission, despite staff interviews indicating that residents should be weighed on admission and upon return from the hospital to establish a new baseline. The facility also failed to ensure physician’s orders for hemodialysis-related assessments were in place for a resident receiving dialysis. This resident was cognitively intact and had multiple diagnoses including anemia, heart failure, hypertension, kidney failure, diabetes, hyperlipidemia, anxiety, depression, bipolar disorder, and asthma, and received dialysis. The care plan for dialysis focused on minimizing complications and included interventions such as checking and changing the dressing at the access site daily, monitoring vital signs before and after dialysis, monitoring and documenting edema and weight gain, and monitoring for signs and symptoms of infection and renal insufficiency. The physician orders included renal care on specific days, maintaining a clean, dry, intact dialysis dressing, and, starting on a later date, orders to monitor the access site for bruising, bleeding, infection, and to assess for thrill and bruit every shift. Review of order history showed no prior physician orders to monitor the access site or assess for thrill and bruit before that later date. The resident reported that staff did not complete assessments after dialysis and had never checked the bruit and thrill, and the DON stated she expected such orders and assessments to be in place but could not explain why they were not ordered earlier.
Failure to Follow Speech Therapy Swallowing and Supervision Recommendations During Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a safe, hazard‑free environment and adequate supervision during meals for residents with specific speech therapy swallowing and positioning recommendations. Facility policies on Activities of Daily Living and Assisted Nutrition and Hydration required care and services to be based on comprehensive assessments, including appropriate assistance with eating and adherence to therapeutic diets and monitoring needs. Despite these policies, staff did not consistently follow speech therapy guidance or provide the ordered level of supervision and positioning during meals for two residents with cognitive impairment and dysphagia‑related needs. For one resident with mild cognitive impairment, neurogenic bladder, malnutrition, cerebellar ataxia, dysphagia, muscle weakness, and a documented dependence on staff for eating, the MDS showed the resident was dependent with eating and receiving speech therapy. A speech therapy evaluation documented that this resident required 1:1 feeding assistance, supervision for swallow safety 91–100% of the time at meals, and skilled ST three times a week to address swallowing and communication deficits. Physician orders included a regular diet with thin liquids and nutritional supplements. However, on multiple observations, the resident was found lying prone in bed on his/her stomach, self‑feeding regular meals and liquids without staff present or monitoring. On one occasion, staff entered only after the meal to remove the tray, leaving food pieces under the resident; on another, the resident coughed loudly and harshly and spit out food while continuing to eat unassisted. The Director of Therapy and the speech therapist both stated they expected the resident to be up in a chair for meals when possible and to have oversight if eating on his/her stomach, and the Administrator and DON stated they expected staff to provide protective oversight during meals when ordered. For a second resident with moderate cognitive impairment, stroke, dementia, and anxiety, the MDS indicated a need for partial to moderate assistance with eating. The care plan identified a potential nutritional problem related to dementia and directed staff to provide dining assistance such as tray setup, cutting food, identifying items, and feeding as needed. A swallowing strategies sign posted in the resident’s room instructed staff to assist with cutting food and tray setup, provide supervision at mealtimes, maintain an upright position during meals, and ensure small bites, slow rate, and alternating food and liquids. Despite these instructions, surveyors observed the resident slumped in bed, eating ground sausage with fingers, with the meal tray on a bedside table and no staff supervision. On another observation, the ADON and a CNA positioned the resident in bed and set up the meal but then left the room, after which the resident again ate with fingers without supervision, while the swallowing strategies sign remained posted. A CNA, the speech therapist, and the DON each confirmed that staff were expected to follow the posted swallowing strategies, keep the resident upright, and supervise the resident during meals, which was not done during the observed meals.
Care Plans Did Not Match Active Diet and Code Status Orders
Penalty
Summary
The facility failed to ensure resident care plans were revised to reflect individual care needs for 2 of 47 sampled residents. For Resident #12, the most recent quarterly MDS showed an admission date of 3/10/23, some cognitive impairment, and diagnoses including diabetes, CKD, atherosclerotic heart disease, and heart failure. The resident’s record contained conflicting code status information: a DNR signed by the resident’s representative and hospice physician was filed in the code status book, while the medical record also contained an active physician order for full code, a scanned DNR order, and an electronic banner showing full code. The care plan in use identified the resident as full code and included interventions stating the resident had completed a full code directive. For Resident #143, the quarterly MDS showed an admission date of 7/15/25, no cognitive impairment, and diagnoses including gastrostomy placement, history of sepsis, CHF, and dysphagia. Observation and interview showed the resident receiving pureed meals, and the resident stated he/she received pureed breakfast and lunch. However, the care plan focused on aspiration risk due to noncompliance with NPO status and on tube feeding needs, with interventions for tube placement checks, head-of-bed elevation, and a quarterly RD consult, but it did not include the resident’s active diet orders or nutritional needs. The active physician orders showed a regular diet with pureed texture and an NPO after midnight order, with no active tube feeding order. Staff interviews stated care plans should be individualized and that diet and code status orders should be accurate and reflected in the care plan.
Failure to Communicate With a Non-English Dominant Resident
Penalty
Summary
The facility failed to ensure staff communicated with a non-English dominant resident in a form and manner the resident could understand. The resident’s record showed diagnoses including irregular heartbeat, altered mental status, protein calorie malnutrition, diabetes, and muscle weakness. The hospital discharge summary stated the resident was Cantonese speaking, that a video translator was used, and that the resident was non-English speaking at baseline. The resident’s care plan noted the resident was sometimes understood and sometimes understood others, but it did not direct staff on how to communicate with the resident in a form and manner the resident could access and understand. Observation and interview showed the resident’s room contained a green Buddha figurine and bamboo greenery, and an English-only activity calendar was present. During a medication pass, a CMT approached the resident, told the resident it was time to get up and sit on the side of the bed for medications, and handed the resident a liquid nutritional supplement while telling the resident to drink. The CMT stated the resident could understand some English, but there was no communication board available and Google Translate had not been used to explain medications or care. The resident later told the surveyor that staff did not use a communication board, instead pointed to items or used hand gestures, and that the resident could not read the activity calendar in the room. During interview, an LPN stated staff used hand gestures to communicate with the resident and had not received training on the resident’s dominant language, communication boards, or the need for Google Translate. The Administrator and DON stated language preferences should be assessed at admission, staff should use a communication board and/or translation application to communicate with non-English dominant residents, communication methods should be in the care plan, and the activity calendar should be printed in a manner the resident could read and understand. The facility assessment also stated the facility uses communication boards and Google Translate to meet resident language needs.
Incorrect g-tube flush during medication administration
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received the correct water flush during medication administration. The resident had diagnoses including seizures, brain injury, and dysphagia, and the care plan identified that the resident required a feeding tube. The physician orders included enteral feed flushes of 120 ml of water every 4 hours and 120 ml of water before and after medication administration, along with multiple medications to be given via g-tube, including valproic acid, metoprolol tartrate, sodium chloride, amlodipine, levothyroxine, and glycopyrrolate. During observation, an LPN prepared the medications by diluting each one in 30 ml of water and flushed the g-tube with 120 ml of water before giving the medications. After each medication, the LPN administered another 120 ml of water. The LPN stated the order meant to give the medications and then flush after each medication with 120 ml of water. Later interviews showed the order was confusing: one LPN believed the 120 ml flush was to be given after the entire medication pass, while the administering LPN interpreted it as after each medication. The regional nurse stated the order needed clarification and that the intended order was to flush the tube with 120 ml of water before and after the entire medication pass, with 5 ml in between medications per policy.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident with severe cognitive impairment, intellectual disabilities, dementia, Parkinson’s disease, schizoaffective disorder, muscle weakness, cognitive communicative deficit, and bipolar disease. The resident’s MDS indicated a strong preference for choosing clothing, listening to music, being around animals, doing activities with groups, going outside for fresh air, and participating in religious services, and also documented no physical or verbal behaviors. However, the resident’s record showed a care plan focused on communication problems related to dementia and anxiety, with interventions to anticipate and meet needs and monitor non-verbal indicators of discomfort or distress. Despite the resident being documented as alert, restless, tearful, and anxious, staff recorded no behaviors on the treatment administration record across multiple shifts and days. The resident had no psychiatric consultation ordered and no psychiatric visits documented in the record. During observations, the resident was repeatedly found lying in bed in a green hospital gown, yelling loudly enough to be heard in the hallway, with the room dark, blinds closed, and the privacy curtain positioned so the resident could not see into the hall. Multiple staff members walked past the room without entering to determine whether assistance was needed. Interviews showed staff awareness that the resident was anxious and yelling out, but the resident was not being engaged in the manner described by facility policy. The roommate reported the resident yelled out all night. The ST said the resident seemed scared and anxious much of the time and could answer some yes-or-no questions. The NP stated the resident would benefit from one-to-one activities, should not be in a hospital gown, should be out of bed in the common area, and should have a psychiatric consult due to yelling and medication review. The SSD, AD, LPN, CNAs, DON, and Administrator all described expectations that staff should assess needs, provide redirection, offer activities, document behaviors accurately, and obtain psychiatric consultation, but the resident’s record and observations showed these interventions were not provided.
Narcotic Medication Not Double-Locked or Counted
Penalty
Summary
The facility failed to ensure a narcotic medication was stored under a double lock and counted when a resident was admitted and destroyed when the resident discharged from the facility. Resident #179 had diagnoses including chronic kidney disease, muscle weakness, and dementia, with moderately impaired cognition. The resident was discharged with all personal belongings and was escorted to a long term care facility in a personal vehicle by the resident's son, with discharge paperwork given to the son. On observation, the nurse's medication cart on the loop hallway contained a grocery bag with a ziplock bag of medication bottles labeled with the resident's name, and the medication was not behind a double lock. The loop medication cart narcotic count sheet did not include the resident's Tramadol. The same medication bag was later observed on the counter in the medication storage room, still not double locked, and contained one bottle of Tramadol dated 4/6/25 with 16 pills. Staff interviews confirmed the Tramadol belonged to the discharged resident, had been brought to the facility on admission, and should have been counted on a narcotic count sheet every shift but was not.
Inappropriate meal substitutions for resident on therapeutic diet
Penalty
Summary
The facility failed to assure that a resident received meals with appropriate nutritive content as prescribed by the physician and consistent with the resident’s treatment plan and preferences. The resident had multiple diagnoses including anemia, heart failure, hypertension, renal failure, diabetes, and hyperlipidemia, weighed 209 pounds, received dialysis, required set-up or clean-up assistance with eating, and was on a therapeutic diet with fluid restriction. The care plan and nutritional assessment identified the need to monitor diet tolerance and acceptance and to provide the diet as ordered. The resident’s diet orders changed over time and included a controlled carbohydrate and renal-related diet with fluid restriction, later changed to a controlled carbohydrate/no added salt diet with restrictions on orange juice, bananas, and tomato products. Nutrition notes documented that the resident wanted lower sodium foods and that the tray card was updated with preferences. The resident also told staff he/she was supposed to have a high protein diet and complained that meals were different from those served to other residents, including being served potatoes instead of other vegetables, ground beef instead of baked chicken, and no dessert or juice. Survey observations showed the resident was served meals that did not match the meal tickets or menu items and did not include an appropriate substitute for starches. On one occasion, the resident was served grilled cheese, green beans, and applesauce even though the meal ticket noted protein, vegetables, and fruit only with no starch. On another occasion, the resident’s tray contained baked chicken and broccoli while the menu listed a meal with turkey burger patty, stuffing, broccoli, and fruit. On a later occasion, the resident was served baked fish, carrots, and pudding while the menu listed fish with wild rice pilaf and fruit. The RD stated the resident had requested limited starches and bread and that if starches were removed, an extra vegetable could be added, but was unsure whether the resident received enough food to meet caloric needs. The Administrator and DON stated they would expect appropriate substitutes for residents who decline starches or other carbohydrates and that staff should ensure adequate calories to meet medical needs and preferences.
Infection Control Failures With Catheter Care and Reusable Equipment
Penalty
Summary
The facility failed to follow current CDC guidelines and its own infection control policies for two residents. One resident had a urinary catheter and was identified in the record as cognitively intact with diagnoses including chronic a-fib, history of sepsis, hydronephrosis with ureteral calculus obstruction, and history of digestive system surgery. The resident’s quarterly MDS showed an admission date of 2/4/25. Observation showed the resident with a urinary catheter bag hanging from the wheelchair, and on one occasion staff emptied the catheter without PPE. On other observations, no EBP signage was present at the door and no PPE storage caddy was located outside the room, despite the resident having an indwelling urinary catheter. The facility’s EBP policy stated that residents with indwelling medical devices, including urinary catheters, should have EBP orders, with gowns and gloves available near or outside the room, and that EBP should continue for the duration of the device. During interview, the Infection Preventionist, Regional Nurse Consultant, DON, and Administrator stated that residents with urinary catheters should be on EBP orders, that staff should wear PPE when providing care, and that signage and PPE caddies should be present for residents with active orders. The observations showed these measures were not in place at the time care was provided. A second resident had osteomyelitis of the left ankle and foot and an order for wound care to cleanse the toes with wound cleaner, apply an abdominal pad, and wrap with Kerlix. During wound treatment, a nurse prepared supplies at the cart, placed wound care items on a towel on the resident’s bed, and set blue-handled scissors directly on the bedside table without cleaning the table or using a barrier. The nurse then used hand sanitizer on gauze and sprayed wound cleaner directly onto the scissors before wiping them and cutting off the dressing. The nurse later stated the scissors should have been cleaned with disinfecting wipes approved for reusable medical equipment, and the Infection Preventionist, Regional Nurse Consultant, DON, and Administrator stated reusable equipment should be cleaned per manufacturer recommendations or CDC guidance using the facility’s germicidal wipes.
Failure to Provide Timely Personal Hygiene Due to Linen Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene and bathing, to residents who required such care. Two residents who were dependent on staff for bathing and personal hygiene did not receive showers as scheduled, with one resident reporting not having had a shower for over two weeks. Both residents expressed that the lack of clean towels and washcloths contributed to missed showers and delays in personal care. Staff interviews confirmed that towel and linen shortages were a recurring issue, impacting their ability to provide timely hygiene care. Observations and interviews revealed that multiple units, including the Memory Care unit, 500-hall, and rehab hall, experienced shortages of towels and washcloths. Linen carts were often not restocked until late morning or afternoon, and clean linen closets were found empty during morning care times. Staff reported having to wait for laundry to be completed or for carts to be restocked, sometimes resulting in residents not receiving showers or having their beds made. Disposable wipes were available in limited quantities, but staff primarily relied on regular linens, which were insufficient to meet resident needs. The facility's laundry and linen management practices contributed to the deficiency. Staff described inconsistent restocking schedules, locked laundry rooms, and reliance on emergency supplies or family-provided items when shortages occurred. Despite recent purchases of linens and new equipment, staff and residents continued to report inadequate access to necessary supplies for personal care. The deficiency was further evidenced by direct resident complaints, staff interviews, and observations of empty linen storage areas during surveyor visits.
Failure to Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Staff failed to follow established infection prevention and control protocols, specifically Enhanced Barrier Precautions (EBP), during high-contact care activities for two residents with wounds and indwelling catheters. Despite clear physician orders and care plans requiring the use of gowns and gloves during such activities, observations revealed that staff only donned gloves and omitted gowns while performing wound care and transfers. EBP signage and supply bins were present, but staff did not consistently adhere to the required use of personal protective equipment (PPE) as outlined in facility policy and CDC/CMS recommendations. Additionally, the facility did not maintain proper management of catheter drainage bags. On multiple occasions, a resident's catheter drainage bag was observed lying on the floor and not placed in a privacy bag, contrary to facility policy. Interviews with staff indicated a lack of clarity regarding the location of privacy bags and inconsistent understanding of proper catheter bag handling, despite recent training. Staff acknowledged that drainage bags should not touch the floor and should be covered, but these practices were not followed during the survey. The facility also failed to ensure food safety standards were met when a dietary aide transported uncovered plated food on a cart via the elevator. The administrator confirmed that food should be covered during transport, but observations showed several plates without lids. These lapses in infection control and food safety practices were directly observed and confirmed through staff interviews and record reviews.
Failure to Document and Administer Tube Feedings and Blood Pressure Monitoring
Penalty
Summary
Staff failed to accurately document and administer tube feedings for a resident with a gastric tube, who had a history of high blood pressure, diabetes, traumatic brain injury, and was dependent on staff for all activities of daily living. The resident's care plan included interventions for unplanned weight loss and required tube feedings and water flushes as ordered by the physician. However, multiple entries on the treatment administration record (TAR) were left blank, with no documentation to indicate whether the tube feedings or flushes were administered or refused. Progress notes indicated occasional refusals and disconnections by the resident, but there was no consistent documentation explaining the missed administrations or refusals, as confirmed by the registered dietician who relied on these records to monitor the resident's nutrition. Another deficiency involved the administration of Hydrochlorothiazide, an antihypertensive medication, to a resident with moderate cognitive impairment and a diagnosis of hypertension. The physician's order specified that the medication should not be given if the systolic blood pressure was less than 100, and the care plan required monitoring for side effects and effectiveness. Despite this, the medication administration record showed the medication was given daily without any documentation of the resident's blood pressure prior to administration. Interviews with nursing staff and the nurse practitioner confirmed that blood pressure readings were not consistently documented before giving the medication, even though it was expected per facility policy and physician order. Interviews with facility leadership, including the regional nurse consultant, corporate nurse, and administrator, confirmed expectations that staff should document all treatments and medications administered, as well as vital signs when required by physician orders. The facility's policy required documentation of all assessments, observations, and services at the time of service or by the end of the shift, but this was not consistently followed in the cases reviewed.
Failure to Timely Transcribe Orders and Accurately Document Wound Care
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for multiple residents, as evidenced by untimely transcription of new treatment orders and inaccurate documentation of treatments. For one resident with a stage 2 pressure ulcer, staff did not consistently document wound care treatments on the Treatment Administration Record (TAR), with several missed entries and no explanation for delays in starting prescribed treatments. Additionally, after a surgical procedure resulting in a wound vacuum being placed, there was no physician order for the wound vac, and documentation of wound care remained incomplete. Another resident admitted with multiple pressure injuries, including a stage 4 ulcer and deep tissue injuries (DTIs), did not have all wounds identified or documented upon admission. The admitting nurse failed to document the presence of DTIs, and treatment orders for wounds were not initiated until several days after admission, with no documentation that the physician was notified of the delay. Hospital discharge instructions for wound care were not promptly transcribed or implemented, and the required skin assessment lacked complete wound descriptions. A third resident with a stage 4 pressure ulcer and additional wounds also experienced lapses in treatment documentation. Several wound care treatments and g-tube flushes were not documented as administered, and there was no record explaining the missed treatments or whether the physician was notified of delays in starting new orders. Interviews with facility staff confirmed that nurses were responsible for entering and documenting orders, and that documentation should occur at the time of service, but these practices were not consistently followed.
Failure to Monitor Nutritional Status and Obtain Required Weights
Penalty
Summary
A deficiency occurred when staff failed to monitor a resident's nutritional status and the effectiveness of interventions by not obtaining admission and weekly weights as ordered for a resident diagnosed with severe protein-calorie malnutrition. The facility's policy required a comprehensive nutritional assessment upon admission, including obtaining a weight within the first 24 hours and weekly weights for four weeks, but these were not consistently completed. Documentation repeatedly showed weights were not obtained, with no explanation or evidence of further attempts to secure the required measurements, despite clear orders and the resident's high risk status. The resident in question had a history of vascular dementia with behavioral disturbance and was admitted with severe chronic malnutrition, as evidenced by severe fat and muscle loss and intake of less than 75% of estimated needs. Hospital records and facility documentation indicated variable oral intake, with the resident consuming most of the prescribed nutritional supplement but less than 50% of meals. Despite these concerns, the facility failed to document weights at admission and on a weekly basis, and there was no documentation of why weights could not be obtained or of any follow-up actions to address the missed weights. Interviews with facility staff, including the registered dietician, LPNs, nurse practitioner, and regional nurse consultant, confirmed expectations that weights should be obtained upon admission and weekly thereafter for new admissions, especially for residents at nutritional risk. However, the records showed ongoing failures to obtain and document weights, and staff were not notified of significant weight changes. The lack of consistent weight monitoring and documentation for this resident with severe malnutrition constituted a failure to follow facility policy and ensure adequate monitoring of nutritional status.
Failure to Provide Necessary Behavioral Health Services and Accurate Medication Administration
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with vascular dementia and behavioral disturbances. The resident was admitted with a history of violent and explosive behaviors, including physical aggression toward staff and other residents, paranoia, delusions, and non-compliance with care. Despite these documented behaviors, facility staff failed to accurately document the resident's behaviors, often recording 'no behaviors' on monitoring tools, even when there were reports of refusals, hitting, disrobing, and attempts to ambulate without assistance. Interviews with CNAs and LPNs confirmed the presence of aggressive and non-compliant behaviors, but these were not reflected in the official documentation or behavior monitoring records. The facility also failed to administer psychotropic medications as ordered and did not accurately document medication administration or refusals. Medication Administration Records (MARs) indicated that medications such as Rexulti, Olanzapine, Valproic Acid, Lexapro, and Mirtazapine were documented as administered, but pharmacy records and medication counts revealed discrepancies. For example, the supply of Rexulti and Olanzapine on hand did not match the number of doses documented as given, and staff interviews revealed that some medications were not available or not administered as ordered. Additionally, there was a lack of documentation regarding medication refusals, despite staff and CNA reports that the resident sometimes spit out or refused medications. The facility's policies required clear and accurate documentation of behaviors, medication administration, and refusals, as well as the development and regular review of a behavioral management plan. However, the interdisciplinary team did not ensure that the resident's behaviors were properly identified, documented, or addressed in the care plan. The lack of accurate documentation and failure to administer medications as ordered resulted in the resident not receiving necessary behavioral health care and services, as required by facility policy and regulatory standards.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
Facility staff failed to protect a resident with dementia, restlessness, agitation, and cognitive communication deficits from physical abuse. On the day of the incident, a certified medication technician (CMT) engaged in a verbal altercation with the resident after the resident coughed or pretended to cough on another staff member. The CMT used profanity, called the resident derogatory names, and both parties exchanged threats. The situation escalated when the CMT pushed the resident, who pushed back, leading the CMT to strike the resident around the face and neck, pushing the resident against the wall. Other staff intervened, pulling the resident away, which resulted in the resident falling to the ground. The resident sustained visible injuries to the neck and hand. Multiple staff members were present during the incident, and their accounts varied. Some staff initially wrote statements indicating the resident attacked the CMT, but later interviews and a second statement from one CNA described the CMT as the aggressor, using physical force and continuing to attempt to strike the resident even after the resident was on the ground. The resident reported being assaulted by the CMT and expressed feeling unsafe and distrustful of the staff. Physical evidence of injury was observed and measured by the wound nurse, including scratches on both sides of the neck and on the hand. The facility's abuse policy required immediate protection and investigation of alleged abuse, but the initial response focused on staff statements that framed the resident as the aggressor. The nurse and DON did not specifically ask the resident if they had been assaulted, and the initial staff statements were collected in a group setting, with some staff later reporting feeling coerced to match their accounts. The incident was not immediately reported as abuse, and the resident's allegations and injuries were not promptly or thoroughly investigated according to policy requirements.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an altercation between a resident and several staff members, resulting in the resident sustaining scratches on both sides of the neck and on the left hand. The initial response involved a registered nurse collecting written statements from the involved staff, but these statements were written and read aloud in front of each other, compromising the integrity of the investigation. The following day, a certified nurse aide reported to the Director of Nursing (DON) that their initial statement was inaccurate and provided a new account alleging that a staff member had assaulted the resident. Despite this new information, the DON did not further investigate the incident, did not interview the resident or other staff members privately, and did not inform the Administrator of the revised statement. The facility's own policy required immediate and thorough investigation of any allegations or suspicions of abuse, including private interviews with all involved parties and prompt reporting to the Administrator and relevant authorities. However, the investigation was limited to collecting initial written statements, with no documentation of resident interviews or private staff interviews. The DON also failed to ensure that the new allegation of staff-to-resident assault was reported or investigated according to policy. The Administrator was not made aware of the revised statement or the resident's allegations, and the incident was not reported to state agencies as required. The resident involved had a history of agitation and conflict with the staff member in question, and after the incident, was observed with visible injuries and reported feeling unsafe and distrustful of the staff. Multiple staff interviews revealed inconsistencies in their accounts, with at least one staff member stating they felt coerced into writing a false statement. The facility's failure to conduct a thorough, unbiased investigation and to follow its own abuse reporting policies resulted in a deficient practice affecting at least one resident.
Failure to Administer Prescribed Anti-Seizure Medication and Notify Physician
Penalty
Summary
The facility failed to administer a resident's prescribed anti-seizure medication, Levetiracetam, as ordered by the physician, resulting in nine out of ten missed doses over a five-day period. Documentation in the resident's medical record indicated that the medication was not available to staff, and there was no evidence that the physician or the Director of Nursing (DON) was notified of the missed doses. The facility's medication administration policy required that discrepancies with medication orders or supplies be reported to the nurse manager, and that the e-kit, which contained an emergency supply of Levetiracetam, be used in such situations. However, staff did not utilize the e-kit or follow the notification procedures outlined in the policy. The resident, who had a history of diabetes, stroke, and Moyamoya Disease, had a physician order for Levetiracetam 500 mg twice daily. The resident reported going without the seizure medication for almost a week, expressing fear of experiencing another seizure, especially given a recent diagnosis of a seizure disorder that had previously led to a heart attack. The resident and a family member both reported making multiple requests for the medication and seeking information from facility staff, but were only told that the issue was being addressed, without specifics or resolution until after the missed doses. Interviews with facility staff and pharmacy representatives confirmed that the medication was not administered due to it being unavailable, and that the pharmacy had last delivered a 30-day supply several days prior to the missed doses. Staff acknowledged that the e-kit contained an emergency supply of the medication and that procedures required immediate re-ordering and notification of the DON when medications were missing. Despite these protocols, the necessary steps were not taken, resulting in the resident missing nearly all scheduled doses of a critical medication over several days.
Significant Medication Errors: Incorrect Dosing and Improper Administration of Depakote
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by incorrect medication dosing and improper medication administration practices. One resident was admitted with a hospital order for Divalproex (Depakote) 250 mg three times daily, but the facility entered and administered a lower dose of 125 mg three times daily for six days. This discrepancy was not accompanied by any documentation of a physician order change or justification in the medical record, despite facility policy requiring orders to match hospital discharge instructions unless otherwise directed by a provider. Additionally, staff failed to follow manufacturer and pharmacy recommendations regarding the administration of Depakote delayed release tablets. Multiple residents received their Depakote tablets crushed, despite clear labeling and manufacturer instructions stating that the medication should not be crushed. In one case, a resident who had difficulty swallowing and often refused medication was given crushed Depakote after a physician order was obtained to crush medications. However, the medication card was labeled "do not crush," and the staff did not have a do not crush list available. Another resident also received crushed Depakote due to dietary needs, with the medication administered in pudding. These actions resulted in at least one resident being hospitalized with a low therapeutic level of Depakote, as confirmed by hospital laboratory results. Interviews with staff, including the DON and pharmacist, confirmed that crushing delayed release Depakote is not recommended and can affect the medication's effectiveness. The facility's medication administration policy required staff to administer medications as ordered and in accordance with manufacturer specifications, which was not followed in these instances.
Staff Cell Phone Use and Profanity Violate Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents when a Certified Nurse Aide (CNA) used profanity while on a personal cell phone during feeding assistance to a resident with severe cognitive impairment. This incident occurred in the presence of a Certified Medication Technician (CMT) who did not intervene. The resident, who required partial to moderate assistance for eating due to conditions such as dementia and malnutrition, was unable to respond to questions during an attempted interview. The CNA admitted to using profanity and acknowledged the inappropriateness of using a cell phone while assisting the resident. Additionally, four other residents, all cognitively intact and diagnosed with anxiety and depression, reported issues with staff being on their phones while providing care. These residents expressed that some aides were disrespectful, often using their phones during work hours, and some even wore earphones, ignoring the residents. The residents found this behavior rude and unprofessional, indicating a broader issue with staff conduct and adherence to facility policies. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Director of Nurses (DON), and the Administrator, confirmed that personal cell phone use while providing care is against facility policy. The DON noted that staff had recently received training on cell phone use and customer service, but the CNA involved in the incident was not documented as having attended. The Administrator acknowledged the need for additional education for the staff involved in the incident.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained at a safe and appetizing temperature. Three out of six residents, who ate their meals in their rooms, reported that hot foods were often served cold. Observations revealed that the tray cart, which is designed to keep food warm, was not consistently plugged in during meal service. This resulted in food temperatures falling below the required 120 degrees Fahrenheit, with mashed potatoes and spinach recorded at 108 and 105 degrees Fahrenheit, respectively, and an omelet at 114 degrees Fahrenheit. Interviews with residents and staff highlighted a lack of communication and training regarding the importance of keeping the tray cart plugged in to maintain food temperatures. A resident mentioned that staff would reheat food in the microwave upon request, indicating a workaround for the issue. However, a CNA admitted to not being informed about the necessity of keeping the cart plugged in, and the Dietary Manager confirmed that the cart should remain plugged in during service. The facility's administrator also expressed the expectation that the cart should be plugged in until all trays are served.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not dating opened packages of food. During an observation in the main kitchen, several opened food packages, including brown gravy, bowtie pasta, and spaghetti noodles, were found wrapped in plastic wrap without any dates. This oversight indicates a failure to follow the facility's policy, which requires all opened food items to be sealed, labeled, and dated before being returned to storage. Additionally, the facility did not maintain cleanliness in the dining areas and kitchen equipment. Observations in the 3rd floor kitchenette and dining room revealed dead roaches in drawers and cabinets, along with food crumbs and dried stains. The presence of roaches and bait traps, along with the lack of awareness from staff about these conditions, highlights a significant lapse in maintaining a sanitary environment as per the facility's sanitation policy. Furthermore, the facility failed to properly clean kitchen equipment, specifically the steam table wells. Observations showed dirty, frothy water with food particles in the steam table wells, which were not cleaned before adding clean water and placing food pans. Interviews with staff, including the Dietary Manager and Administrator, revealed a lack of consistent adherence to cleaning protocols, with responsibilities for cleaning and food labeling not being effectively communicated or enforced among staff members.
Deficiency in Maintaining Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that prepared food items were served at a safe and appetizing temperature, as observed during a survey. The internal temperatures of hot food items were not maintained at 135 degrees Fahrenheit or higher, which is necessary to prevent the growth of food-borne pathogens. This deficiency was noted during an observation where the internal temperatures of various food items, such as chocolate pudding, hush puppies, breaded/fried fish, and green beans, were recorded at significantly lower temperatures than required. Additionally, the Tray Line Food Temperature Log showed no recorded temperatures for the lunch meal on the day of observation. Interviews with residents revealed dissatisfaction with the food temperatures, with one resident stating the food was usually cold and another mentioning it was warm but not hot. The Dietary Manager confirmed that food temperatures were taken before serving but were not logged, and expressed an expectation for hot food to be hot and cold food to be cold. The Administrator acknowledged the issue, noting that the insulated food carts were old and might need replacement, and emphasized the importance of meeting regulatory temperature standards.
Failure to Administer Diabetes Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of diabetes medications. The resident, who was cognitively intact and had diagnoses including diabetes, heart failure, and chronic kidney disease, did not receive prescribed medications, Farxiga and Trulicity, for several days. The facility's records showed that these medications were marked as unavailable on multiple occasions, and there were no progress notes explaining the non-administration of Trulicity. The Director of Nursing (DON) acknowledged that the facility failed to administer the resident's Trulicity medication, which was intended for weight loss rather than diabetes. The DON explained that the pharmacy required approval for the medication, which was delayed, and the nurses failed to notify the pharmacy or the DON about the unavailability of the medication. The nurses marked the medication as unavailable and informed the doctor but did not follow up with the pharmacy or the DON. The admission nurse was responsible for verifying orders with the physician, and the Assistant Director of Nursing (ADON) was responsible for auditing admissions. The DON discovered during a medication audit that the pharmacy had approval for Farxiga but did not deliver it to the facility. Additionally, the pharmacy sent only three-day doses instead of the full card, leading to missed doses. The staff did not notify the DON about the medication's absence, and there was a lack of communication between the facility and the pharmacy regarding the medication's delivery and administration.
Resident Aggression Leads to Physical Abuse in LTC Facility
Penalty
Summary
The facility failed to ensure that four residents were free from physical abuse, as evidenced by incidents involving a resident who physically assaulted other residents. The incidents occurred when a resident, who was severely cognitively impaired and had a history of aggressive behavior, hit other residents in the face and stomach. The facility's records showed that the resident had previously exhibited combative behavior towards staff and other residents, and had been sent to the hospital multiple times for evaluation due to aggressive behaviors. The resident's care plan included interventions for behavior management, but there were no new documented behavioral interventions after a certain date, prior to the assault. Staff interviews revealed that the resident's aggressive behavior was unpredictable and difficult to manage, especially when staffing levels were low or when only female staff were present. The resident's aggressive actions were not effectively mitigated, leading to physical harm to other residents. The facility's policy on abuse, neglect, and exploitation was in place, but the implementation of preventive measures and interventions was insufficient to protect residents from harm. The staff's inability to redirect the resident and the lack of effective interventions contributed to the occurrence of physical abuse among residents. The facility's failure to adequately address the resident's aggressive behavior resulted in a violation of the residents' right to be free from abuse.
Failure to Incorporate PASARR Recommendations in Resident Care Plan
Penalty
Summary
The facility failed to ensure timely completion of pre-admission screenings and did not incorporate recommendations from the PASARR Level II determination into the care plan for a resident. The resident, who had a history of chronic kidney disease, diabetes, schizophrenia, and unspecified mood disorder, was admitted without the necessary PASARR Level II evaluation being completed prior to admission. The evaluation, which was completed after admission, identified the need for specific supports and services, including a structured environment, behavioral support plan, and medication therapy, which were not initially included in the resident's care plan. The resident's care plan was found lacking in several areas, including the absence of a behavioral support plan until after the resident's behavior escalated. There was no documentation of assessing and planning for meaningful socialization and recreational activities to prevent isolation, nor was there development of personal supports to prevent isolation in the community. The care plan also failed to include the necessary supports and services identified in the PASARR Level II evaluation, such as monitoring of behavioral symptoms and provision of a structured environment. Interviews with facility staff revealed that the resident was difficult to manage due to a history of incarceration and trauma, which contributed to his/her rigid behavior and difficulty adapting to the facility environment. Staff reported that the resident was not very social and often isolated, and there was a lack of direction on how to manage his/her behavior. The MDS coordinator acknowledged the oversight in the care plan, attributing it to being new to the facility and trying to catch up on care plans. The administrator admitted that the resident's behavioral issues were not promptly addressed in the care plan, as they were focused on managing the immediate situation.
Failure to Address Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being, as evidenced by the lack of staff intervention in managing the resident's escalating behaviors. The resident, who had a history of chronic kidney disease, diabetes, unspecified mood disorder, schizophrenia, and unspecified psychosis, exhibited behaviors such as verbal aggression, hallucinations, and delusions. Despite these behaviors, the facility did not inform staff on how to handle the resident's escalating behaviors, leading to multiple incidents where the resident became verbally and physically aggressive towards staff and other residents. The resident's medical records and progress notes indicated several instances of inappropriate behavior, including sexually inappropriate comments to staff, calling the police over misunderstandings, and using racial slurs and derogatory language towards staff. On one occasion, the resident became agitated, lunged at a nurse, and called 911 multiple times, alleging abuse by staff. Despite these incidents, staff were not provided with guidance on managing or preventing the resident's behaviors, and the care plan lacked detailed interventions for addressing the resident's behavioral issues. Interviews with staff revealed that they were not given instructions on how to manage or prevent the resident's behaviors, leading to feelings of fear and uncertainty. The facility's investigation noted that the resident had a history of incarceration and trauma, which may have contributed to his behavior, but this information was not adequately reflected in the care plan. The lack of a comprehensive care plan and staff training on handling aggressive behaviors contributed to the facility's failure to meet the resident's psychosocial needs.
Financial Misappropriation by Staff Members
Penalty
Summary
The facility failed to protect a resident from financial misappropriation when two staff members wrongfully used the resident's credit card. The incident began when a resident, who is cognitively intact and diagnosed with end-stage renal disease and muscle weakness, allowed their adult child, also a resident, to use their credit card to purchase a soda from a vending machine. The adult child, who is cognitively intact and diagnosed with diabetes and major depressive disorder, accidentally left the credit card at the vending machine. Later, the resident received a bank alert indicating that their credit card was used at a local restaurant without their permission. The facility's investigation revealed that two CNAs used the resident's credit card to purchase food from the restaurant. The resident confirmed the unauthorized use of their card after contacting the restaurant and subsequently reported the card as stolen to the police. Interviews with the involved parties, including the CNAs and the administrator, confirmed the misuse of the credit card by the staff members. The administrator gathered sufficient evidence to determine that the two CNAs were responsible for the unauthorized transaction.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 799 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Town And Country
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mason Pointe Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens West | 1.6 mi | ★★★★★ | 0 | 0 |
| Brooking Park | 1.6 mi | ★★★★★ | 3 | 0 |
| Garden View Care Center Of Chesterfield | 2.4 mi | ★★★★★ | 1 | 0 |
| Manchester Rehab And Healthcare Center | 2.7 mi | ★★★★★ | 0 | 0 |
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