Athene Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Town And Country, Missouri.
- Location
- 13995 Clayton Road, Town And Country, Missouri 63017
- CMS Provider Number
- 265001
- Inspections on file
- 39
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 47
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.
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.
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.
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.
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.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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