Aurora Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Rolla, Missouri.
- Location
- 1200 Mccutchen Road, Rolla, Missouri 65401
- CMS Provider Number
- 265844
- Inspections on file
- 31
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Aurora Health And Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not complete a comprehensive facility-wide assessment, as the documented assessment lacked specific guidance on shift times and did not address staffing needs for each resident unit. The DON and administrator, though involved in the assessment process, were unaware of the requirement to include unit-specific staffing details.
Staff did not consistently use required PPE or follow Enhanced Barrier Precautions when providing care to two residents with wounds, and failed to display EBP signage on their doors. Additionally, mechanical lifts used for transferring two residents were not sanitized before or after use, contrary to facility policy and manufacturer guidelines. Staff interviews revealed confusion about responsibilities for EBP signage and a lack of awareness regarding proper disinfection protocols.
Staff failed to complete required pre-employment screenings, such as background checks and registry verifications, for multiple new hires before they began working. Documentation showed that several employees started work without all necessary checks being completed, and interviews with the DON, HR director, and administrator confirmed that these screenings were not consistently performed as required by facility policy.
Staff did not report allegations of abuse and neglect involving two residents to DHSS within the required two-hour timeframe. One resident with severe cognitive impairment reported being slapped by an employee, and another cognitively intact resident experienced verbal neglect from a CNA. Delays in reporting occurred due to lapses in responsibility transfer and documentation, as well as communication failures during the administrator's absence.
Staff failed to provide necessary bathing and personal hygiene assistance to multiple dependent residents, with documentation showing that some received only one or two baths or showers per month instead of the required twice weekly. Interviews with residents and staff revealed that chronic understaffing led to missed showers and inadequate hygiene care, as staff prioritized other essential tasks and were unable to complete all required ADLs.
Facility staff did not provide enough nursing staff to meet resident care needs, resulting in missed showers, inadequate personal hygiene, and insufficient assistance with meals and transfers. Multiple residents were observed with poor grooming, and staff reported being responsible for large numbers of residents, including those needing mechanical lifts. Non-nursing staff were only observed assisting during surveyor visits, and both staff and residents confirmed that care tasks were frequently missed due to inadequate staffing.
The DON was assigned to work as a charge nurse on multiple occasions while the facility census exceeded 60 residents, contrary to regulatory requirements. The facility assessment did not specify the DON's full-time status or allocation of hours, and interviews confirmed the DON worked the floor due to staffing shortages and the resignation of the ADON.
Facility staff did not provide a required discharge notice for a resident who was sent to the hospital for suicidal ideation and subsequently denied reentry to the facility. The Social Service Director was unaware of the discharge and reentry rules, and the administrator stated the facility could not meet the resident's care needs but did not follow proper discharge procedures.
Staff did not notify a resident's physician and family after the resident experienced a fall and a separate medical emergency involving vomiting and unresponsiveness. Documentation was lacking for both incidents, and interviews confirmed that the resident's representative was not informed, despite the resident's significant medical history and cognitive impairment.
Staff did not maintain wheelchairs in safe condition for three residents, resulting in torn armrests, worn or missing vinyl, and a bent metal piece secured with a bandage. Staff interviews revealed that required reporting and documentation procedures for equipment concerns were not followed, and maintenance staff were unaware of the issues.
Staff failed to provide necessary nail care and facial hair grooming for several residents with cognitive and physical impairments who required assistance with ADLs. Observations showed residents with long, dirty nails, unkempt hair, and poor clothing condition, despite staff being responsible for these tasks. Staff interviews revealed that a shortage of shower aides led to reduced frequency of showers and inconsistent hygiene care.
An LPN at a long-term care facility misappropriated narcotic medications from seven residents by inaccurately subtracting pills from the narcotic count and taking them without authorization. Despite the facility's investigation concluding no misappropriation, police found empty medication cards with residents' names in the LPN's car. The residents were cognitively intact and experienced occasional pain, receiving scheduled and as-needed pain medications.
The facility failed to report an allegation of narcotic misappropriation involving an LPN to the State Survey Agency within the required 24-hour timeframe. Discrepancies in narcotic counts were noted, and empty narcotic cards were found in the LPN's car. Despite concerns, the corporate office advised against reporting, as the investigation did not substantiate misappropriation.
A resident suffered multiple fractures after falling from a wheelchair during transport due to improper securing by facility staff. The resident was not fastened with a shoulder strap, leading to severe injuries when the vehicle stopped abruptly. The driver was inadequately trained, and the facility failed to monitor proper securing of residents.
The facility failed to maintain the mechanical dishwasher in good repair, leading to ineffective dishwashing and potential cross-contamination. Observations showed the dishwasher's temperature was consistently below the required 120 degrees Fahrenheit, and the facility lacked a temperature log for June 2024. Interviews revealed staff were unaware of the correct temperature standards, and the Dietary Supervisor and administrator were not monitoring the equipment properly.
Facility staff failed to protect resident privacy and confidentiality by leaving EMRs open and unattended, posting personal information in public areas, and not ensuring personal privacy for residents. Observations showed that staff did not adhere to protocols for closing screens or covering residents, and interviews confirmed these lapses in privacy protection.
The facility failed to document neurological assessments after falls for four residents, did not follow physician orders for tube feedings and skin assessments for two residents, and neglected to complete weekly weights for a newly admitted resident. Additionally, the facility did not clarify a medication order or obtain necessary lab values for a resident on Lithium, highlighting lapses in protocol adherence and care quality.
Facility staff failed to provide adequate bathing and personal hygiene for several residents, leading to a deficiency in care. Observations showed residents with greasy hair and strong body odor, and interviews revealed dissatisfaction with infrequent showers. Staffing issues were identified as a contributing factor, with only one shower aide available when two were needed. The discrepancy between care documentation and actual provision resulted in residents not receiving necessary hygiene assistance.
The facility failed to maintain a safe environment by leaving chemicals accessible in the dining room and did not assess two residents for safe self-administration of medications. One resident with COPD had an inhaler from home without a self-medication assessment, and another with GERD had antacids at the bedside without proper authorization. Staff interviews revealed a lack of awareness and adherence to policies regarding chemical safety and medication self-administration.
Facility staff failed to ensure medication regimens were free from unnecessary medications by not obtaining appropriate diagnoses for psychotropic medications in three residents and not limiting as-needed orders to 14 days for another resident. Interviews with staff revealed a lack of adherence to policies requiring diagnoses to match prescribed medications and a 14-day stop date for as-needed psychotropic medications.
The facility failed to obtain reasons for urinary catheter use for two residents, did not update a care plan for one resident, and inadequately documented catheter care for another. The Catheter Care policy lacked guidance on orders and documentation. Staff interviews revealed inconsistencies in catheter care orders and documentation, with challenges noted in using the electronic health record system.
The facility did not post required daily nurse staffing information, including total staff numbers and actual hours worked by licensed and unlicensed nursing staff per shift. Observations over three days showed non-compliance with the policy, which mandates accessible and updated postings. Interviews revealed a lack of responsibility due to a vacant Human Resource position, leading to oversight of this task.
The facility failed to honor residents' right to self-determination by suspending smoking breaks for all residents due to an ongoing investigation. This decision affected residents with varying cognitive impairments, none of whom exhibited behaviors justifying the restriction. Staff confirmed the suspension and offered nicotine patches as an alternative.
Facility staff failed to develop comprehensive care plans for residents who smoke, lacking necessary interventions for supervision, assessment, or safety risks. Interviews revealed a lack of awareness and responsibility among staff regarding the inclusion of smoking in care plans.
Facility staff failed to notify a resident's guardian in a timely manner about an abuse allegation and an injury of unknown source. The resident, who was severely cognitively impaired, had a large bruise on the chest. Despite the facility's policy requiring notification of changes in condition, the guardian was not informed until several days later due to miscommunication among staff.
A resident with severe cognitive impairment reported being held down by a staff member, but the facility delayed investigating the allegation. The facility's policy requires immediate investigation, including interviews with all involved parties. However, interviews with potential witnesses were conducted 11 days later due to a misunderstanding by the administrator regarding the investigation requirements.
Incomplete Facility-Wide Assessment of Staffing Needs
Penalty
Summary
Facility staff failed to complete a thorough facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The facility's assessment, dated 10/09/25, included general staffing numbers for RNs, LPNs, CNAs, and CMTs across shifts, but lacked specific direction or guidance regarding shift times and did not address staffing needs for each resident unit. Observations confirmed the facility was organized into multiple halls, but the assessment did not specify staffing requirements for these individual units. During interviews, both the DON and the administrator acknowledged their involvement in the assessment process but were unaware that the assessment needed to include specific staffing needs for each resident unit.
Failure to Implement Infection Control Procedures and Equipment Disinfection
Penalty
Summary
Facility staff failed to adhere to appropriate infection prevention and control procedures, specifically in the use of Enhanced Barrier Precautions (EBP) and the cleaning of mechanical lifts. Observations revealed that staff did not wear required personal protective equipment (PPE), such as gowns and gloves, during the provision of care for two residents with wounds who required EBP. Additionally, there were no EBP signs on the residents' doors to alert staff of the necessary precautions, and staff interviews indicated confusion about who was responsible for ensuring signage and PPE availability. The care plans for these residents either lacked direction for EBP or were not properly implemented, and staff admitted to not following EBP protocols due to the absence of signage. Further deficiencies were noted in the cleaning and disinfection of mechanical lifts used for resident transfers. Staff were observed transferring two residents using mechanical lifts without sanitizing the equipment before or after use, contrary to facility policy and manufacturer guidelines. Interviews with staff revealed a lack of awareness or understanding regarding the need to disinfect the lifts between uses, with some staff only performing this task for residents known to be COVID-positive. The Director of Nursing and Administrator both stated that lifts should be sanitized before and after each use, but there was no consistent practice or clear policy enforcement observed. The residents involved in these deficiencies were assessed as having moderate to severe cognitive impairment and were dependent on staff for care, including wound care and transfers. The facility's policies required EBP for residents with wounds or indwelling devices and mandated staff training and competence in infection control practices. However, the lack of proper signage, inconsistent use of PPE, and failure to disinfect equipment contributed to the observed lapses in infection prevention and control.
Failure to Complete Pre-Employment Screenings for New Hires
Penalty
Summary
Facility staff failed to complete required pre-employment screenings, including Criminal Background Checks (CBC), Employee Disqualification List (EDL) verification, Family Care Safety Registry (FCSR), and Certified Nurse Aide (CNA) Registry checks for six out of ten sampled employees. Personnel files and timecards revealed that several staff members began working before these screenings were completed or documented, contrary to the facility's policies. For example, one registered nurse's file lacked CNA Registry verification, and another CNA's file was missing FCSR, CBC, and CNA Registry documentation. Additionally, some background checks and verifications were dated after the employees' hire or start dates, indicating that screenings were not completed prior to employment as required. Interviews with the Director of Nursing (DON), Human Resources (HR) director, and administrator confirmed that the HR director was responsible for completing all pre-employment screenings before new hires began work. The current HR director reported insufficient training and acknowledged gaps in the screening process, while the administrator was unaware that screenings were not being completed correctly or timely. The facility's own policies require all pre-employment checks to be finalized before staff members start work, but documentation and staff statements confirmed this was not consistently done.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
Facility staff failed to report allegations of abuse and neglect involving two residents to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility's policy mandates immediate investigation and reporting of such allegations, but documentation showed delays in reporting both incidents. In the first case, a resident with severe cognitive impairment reported being slapped by an employee, but the incident was not reported to DHSS until ten days after the initial report. The Director of Nursing (DON) indicated that responsibility for reporting was transferred to the Regional Nurse Consultant due to shift changes, but the required notification was not completed in a timely manner. In the second case, a cognitively intact resident was subjected to verbal neglect when a CNA refused to toilet the resident and made an inappropriate comment. Although the DON stated the incident was reported by phone to DHSS on the day it occurred, there was no documentation to support this claim, and the official report was not submitted until several days later. During the administrator's absence, the Regional Nurse Consultant was responsible for investigations and reporting but failed to ensure timely submission due to an email issue. The administrator was unaware of the late reporting until after returning from vacation.
Failure to Provide Required Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
Facility staff failed to provide necessary care and assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, to ten residents who were dependent on staff for these tasks. Review of facility records, including Minimum Data Sets (MDS), care plans, and shower sheets, revealed that multiple residents received significantly fewer baths or showers than required by their care plans and facility policy. For example, several residents received only one or two baths/showers per month, despite being assessed as needing assistance with bathing at least twice weekly and as needed. Documentation for some residents showed entire weeks or months without any recorded bathing or showering. Interviews with residents confirmed dissatisfaction with the frequency of showers, with some expressing a desire for more regular bathing and noting that their families had raised concerns with staff. One resident reported receiving a shower for the first time in a long period and noted that staff put dirty clothes back on after bathing, despite the availability of clean clothing. These observations were corroborated by staff interviews, where multiple CNAs and a CMT reported chronic understaffing, which prevented them from completing showers, maintaining good hygiene, or providing oral care. Staff described prioritizing other care tasks, such as toileting, due to time constraints, and acknowledged that showers were often delayed or omitted entirely. Nursing staff, including an LPN and the Director of Nursing, acknowledged that showers were not being completed as required, citing high resident acuity and insufficient staffing as contributing factors. The DON reported being aware of the issue and described attempts to track and reschedule missed showers, but the documentation and staff interviews indicated that the deficiency persisted. The failure to provide regular bathing and hygiene assistance was directly linked to inadequate staffing and time management, as reported by both direct care staff and nursing leadership.
Insufficient Staffing Resulting in Missed Resident Care and Hygiene
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the care needs of residents, as required by the facility assessment and federal regulations. Observations and interviews revealed that multiple residents did not receive adequate personal hygiene, including regular showers, grooming, and oral care. Several residents were observed with long facial hair, disheveled or greasy hair, and long fingernails, indicating a lack of assistance with personal care. Residents reported going weeks without showers and feeling unclean, while staff confirmed that showers and hygiene tasks were often missed due to insufficient staffing. Staff interviews consistently described being assigned to care for large numbers of residents, sometimes up to 28 per aide, including many who required mechanical lifts for transfers. Staff reported that they often had to leave their assigned halls unattended to find assistance for lift transfers, further reducing the time available for other care tasks. During mealtimes, there were not enough aides to assist residents, leading to situations where one staff member was responsible for feeding multiple residents. Non-nursing staff, such as the housekeeping supervisor and social service director, were observed assisting with resident care during surveyor visits, but staff indicated this was not typical practice and only occurred due to the presence of surveyors. The facility's own assessment identified the need to adjust staffing based on resident acuity, census, and care needs, including the high number of residents requiring mechanical lifts. Despite this, staff and residents reported that the actual staffing levels were inadequate to meet these needs. The Director of Nursing and Administrator acknowledged that showers were not completed as scheduled and that complaints about staffing were received from residents and families. The deficiency affected at least five sampled residents and had the potential to impact all residents in the facility.
DON Worked as Charge Nurse Despite High Census
Penalty
Summary
Facility staff failed to ensure that the Director of Nursing (DON) did not work as a charge nurse when the facility's average daily occupancy was 60 or more residents, as required by regulation. The facility assessment indicated an average daily census of 77 residents and identified the DON as necessary for resident care, but did not specify if the DON was a full-time staff member or how many hours were dedicated to the DON role. Additionally, the assessment did not clarify whether the DON was allocated to direct care duties. Review of the nursing schedules for September and October showed that the DON worked multiple night shifts as a charge nurse while the census ranged from 76 to 81 residents. During interviews, the DON confirmed working the floor to provide resident care due to a nurse being out with a medical issue and the recent resignation of the Assistant Director of Nursing (ADON). The DON stated that regional support was assisting with DON tasks during these periods. The Administrator also acknowledged awareness that the DON was working the floor.
Failure to Provide Discharge Notice and Allow Resident Reentry After Hospitalization
Penalty
Summary
Facility staff failed to provide a required discharge notice for a resident who was sent to the emergency department for suicidal ideation. The resident's medical record did not contain a 30-day discharge notice or an emergency discharge notice, as required by facility policy. The Social Service Director, responsible for discharge planning, was unaware that the resident had been denied reentry to the facility and was not familiar with the rules regarding discharging a resident and denying reentry. The administrator confirmed that the resident had a history of suicidal ideations and, after the hospital attempted to discharge the resident back to the facility, the facility decided to deny reentry due to an inability to provide one-on-one care, which they determined was necessary for the resident's safety. The facility's policy requires that residents receive a transfer/discharge notice with specific information, including the reason for discharge, effective date, location, appeal rights, and contact information for advocacy agencies, at least 30 days prior to discharge unless it is an emergency. In this case, the required notice was not provided, and the facility did not follow the proper process for discharging the resident or for denying reentry after hospitalization. Both the Social Service Director and the administrator indicated a lack of awareness of the regulatory requirements for discharge and reentry, contributing to the deficiency.
Failure to Notify Physician and Family of Resident Change in Condition and Fall
Penalty
Summary
Facility staff failed to notify both the physician and the resident's family or representative in a timely manner following significant changes in a resident's condition. Specifically, a resident with cognitive impairment, a history of stroke, high blood pressure, and dementia was found on the floor in their room, but there was no documentation that the family was informed of this fall. Additionally, when the same resident experienced episodes of nausea, projectile vomiting, and a period of unresponsiveness, there was no documentation that the physician was notified of this change in condition. Interviews with facility staff, including the DON, administrator, and LPN, revealed uncertainty and lack of recall regarding whether appropriate notifications were made. The resident's guardian confirmed not being informed about either the fall or the medical episode, and stated that such information was important due to the resident's medical history and inability to communicate these events. The Nurse Practitioner reported being notified of the fall but not the subsequent medical episode, despite being present in the building at the time.
Failure to Maintain Safe and Functional Wheelchairs for Multiple Residents
Penalty
Summary
Facility staff failed to maintain wheelchairs in safe and functional condition for three residents, as observed during a survey. One resident with moderate cognitive impairment was seen using a wheelchair with both armrests torn. Another resident with severe cognitive impairment was observed in a wheelchair with worn armrests and missing vinyl. A third resident, who was cognitively intact, was found using a wheelchair with a bent metal piece connecting the chair to the leg rest, which had been temporarily secured with a medical bandage. Interviews with facility staff, including the maintenance director, RN, administrator, and DON, revealed that staff were expected to report and document wheelchair concerns in a maintenance log, but these issues had not been reported or addressed. The maintenance director was unaware of the problems and stated that repairs were not provided for personal wheelchairs, while the administrator and DON acknowledged that torn armrests and damaged wheelchairs could pose safety concerns, such as the potential for skin tears. The facility's policy required routine inspection and maintenance of resident care equipment, but this was not followed in these cases.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
Facility staff failed to provide adequate care to meet the hygiene needs of four residents who required assistance with activities of daily living (ADLs), specifically in the areas of nail care and facial hair grooming. Observations revealed that residents with severe or moderate cognitive impairment and physical limitations, who did not exhibit behaviors of rejecting care, were found with long and dirty nails, unbrushed or matted hair, unkempt facial hair, and clothing in poor condition. These residents were assessed as needing partial to maximum assistance with personal hygiene, yet their care plans and observed conditions indicated that their hygiene needs were not being met as required. Interviews with staff, including CNAs, RNs, the administrator, and the DON, confirmed that staff were responsible for providing nail care and facial hair grooming on shower days and as needed, as well as daily hair brushing and clothing changes. However, staff acknowledged that due to a shortage of shower aides, residents were only being showered once a week instead of the intended twice a week, which contributed to lapses in personal hygiene care. The facility's policy directed staff to assist residents with ADLs but lacked specific guidance on when and how to provide personal hygiene, further contributing to inconsistent care.
Misappropriation of Narcotic Medications by LPN
Penalty
Summary
The facility staff failed to prevent the misappropriation of narcotic medications belonging to seven residents. An LPN was found to have taken these medications without authorization. The facility's Abuse, Neglect, and Exploitation Policy defines misappropriation as the wrongful use of a resident's belongings or money without permission. The facility's investigation revealed discrepancies in the narcotic counts, with the LPN inaccurately subtracting pills from the count for multiple residents. Despite the facility's conclusion that no pills were misappropriated, the police found empty narcotic cards with residents' names in the LPN's car. The investigation showed that the LPN had signed out medications but subtracted more pills than administered, and in some cases, wasted pills without a witness. The police report confirmed the presence of empty medication cards in the LPN's car, which were linked to the residents. The residents involved were cognitively intact and experienced occasional pain, receiving scheduled and as-needed pain medications. The facility's investigation was unable to substantiate the misappropriation despite the evidence found by the police. Interviews with the facility's administrator and DON indicated that they were aware of the allegations and had initiated an investigation. However, they concluded that the narcotic counts were correct and the investigation was unsubstantiated. The LPN did not cooperate with the investigation and did not return to the facility. The LPN claimed to have mistakenly taken narcotic log sheets and denied taking any medications from the facility, despite the evidence found in their car.
Failure to Report Alleged Misappropriation of Narcotics
Penalty
Summary
The facility staff failed to report an allegation of misappropriation of narcotics to the State Survey Agency within the required 24-hour timeframe, as per their policy and state law. This deficiency involved seven residents out of a sample of ten, with a facility census of 78. The facility's Abuse, Neglect, and Exploitation Policy mandates reporting alleged violations to the administrator, state agency, and other required agencies within specified timeframes. The issue arose when discrepancies in the narcotic count were noted, and medications were reportedly given outside the scheduled timeframe by an LPN. Despite attempts to interview the LPN, they did not return to the facility, and the Director of Nursing (DON) contacted the police after empty narcotic cards were found in the LPN's car. The facility did not report the alleged misappropriation to the Department of Health and Senior Services within the required timeframe. Interviews with the administrator, DON, and Assistant Director of Nursing (ADON) revealed that the corporate office advised against reporting the incident, as the investigation did not substantiate any misappropriation despite the discovery of empty narcotic cards. The DON and ADON expressed concerns about the narcotic counts and the inability to interview the LPN. The Regional Nurse Consultant also confirmed awareness of the situation but stated that without a proven allegation, it was not deemed reportable to the state.
Neglect in Resident Transportation Leads to Severe Injuries
Penalty
Summary
Facility staff failed to protect a resident from neglect during transportation in a facility vehicle. The incident occurred when the staff did not properly secure the resident with a shoulder strap while transporting them from a dialysis clinic. As a result, when the vehicle came to an abrupt stop, the resident fell over the lap belt and out of the wheelchair, leading to multiple fractures, including both femurs, thoracic spine, and an upper arm. The resident involved was cognitively intact but had impairments in both lower extremities and was dependent on staff for movement. The facility's investigation revealed that the van driver, identified as Driver A, did not secure the shoulder strap because the resident did not like it. The driver was not trained using the manufacturer's Device User Instructions Manual, and the training provided did not include the use of the shoulder strap. The administrator acknowledged that the facility did not monitor whether transport drivers were securing residents properly before transport. Additionally, the original training documentation for Driver A could not be located, indicating a lapse in ensuring that staff were adequately trained and compliant with safety protocols.
Dishwasher Temperature Non-Compliance
Penalty
Summary
The facility staff failed to maintain the mechanical dishwasher in good repair, resulting in ineffective washing and sanitizing of dishes, which could lead to cross-contamination affecting all residents. Observations revealed that the dishwasher's water temperature was consistently below the required 120 degrees Fahrenheit, with readings of 102, 110, 106, and 108 degrees Fahrenheit during various wash and rinse cycles. The facility's Dishwasher Temperature policy mandates that the water temperature for low-temperature dishwashers with chemical sanitation should be 120 degrees Fahrenheit, and temperatures should be recorded prior to each meal or after the dishwasher is emptied or refilled. However, the facility did not have a temperature log for June 2024, indicating a lack of compliance with their own policy. Interviews with the dietary staff and supervisor revealed a lack of awareness and adherence to the required temperature standards. Dietary Aide F admitted to not checking the dishwasher temperature on the day of observation and was unsure if others had done so. Dietary Aide G incorrectly believed that any temperature over 100 degrees was acceptable, while the Dietary Supervisor acknowledged that the dishwasher usually required three cycles to reach the correct temperature but was unaware of the missing temperature log for June 2024. The administrator also expressed a lack of awareness regarding the correct dishwasher temperature and any existing issues prior to the survey, indicating a systemic failure in monitoring and maintaining kitchen equipment.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility staff failed to protect the personal and medical information of residents, as evidenced by several observations and interviews. On multiple occasions, electronic medical records (EMR) were left open and unattended on a tablet at the nurses' desk, making resident information visible to visitors, residents, and staff. Interviews with various staff members, including a CNA, LPN, and the Director of Nursing, confirmed that the protocol was to close or clear the screen when unattended to ensure privacy, but this was not adhered to. Additionally, resident information was publicly displayed in the facility, compromising confidentiality. Observations revealed that care instructions, adaptive equipment lists, and dietary orders were posted in public areas, such as the CNA station and on an ice chest, making them visible to anyone passing by. Interviews with the facility's staff, including the Corporate Quality Assurance representative and the administrator, acknowledged that such information should not be publicly accessible and should be kept private to protect resident privacy and dignity. The facility also failed to provide personal privacy for residents, as observed in the cases of two residents who were exposed in their rooms with doors open to the hallway. Staff walked by without assisting or ensuring privacy by closing doors or using privacy curtains. Interviews with CNAs, LPNs, and the Director of Nursing indicated that staff were expected to provide privacy by covering residents or using privacy curtains, but this was not done. The administrator admitted to being unaware of the lack of privacy curtains and acknowledged the expectation for residents to have privacy curtains around their beds.
Deficiencies in Documentation and Adherence to Physician Orders
Penalty
Summary
The facility failed to maintain professional standards of care by not documenting follow-up neurological assessments after falls for four residents. These residents experienced unwitnessed falls, and the facility's policy required neurological checks to be conducted and documented. However, the medical records for these residents did not contain the necessary documentation of neurological checks, which is a critical step in assessing potential brain injuries following a fall. Additionally, the facility did not adhere to physician orders for two residents who required tube feedings and skin assessments. One resident did not receive documented tube feedings and flushes as ordered, and another resident did not have weekly skin assessments documented as required. Furthermore, the facility failed to complete weekly weights for a newly admitted resident, which is essential for monitoring the resident's nutritional status and overall health. The facility also failed to clarify a medication order and obtain necessary lab values for a resident receiving Lithium, a medication that requires regular blood level monitoring to prevent toxicity. The resident's physician order sheet did not include an order for lithium level monitoring, and staff interviews revealed a lack of awareness and follow-through on this critical aspect of care. These deficiencies highlight significant lapses in following established protocols and physician orders, potentially compromising resident safety and care quality.
Inadequate Bathing and Hygiene Care for Residents
Penalty
Summary
The facility staff failed to provide adequate bathing and personal hygiene for six out of twelve sampled dependent residents, leading to a deficiency in care. The facility's policy requires that residents receive showers as per request or schedule, with CNAs responsible for assessing skin changes during bathing. However, observations and interviews revealed that several residents had greasy, disheveled hair, strong body odor, and expressed dissatisfaction with the infrequency of showers. For instance, Resident #9, with moderate cognitive impairment and Alzheimer's, was observed with greasy hair and a strong odor of urine, despite the care plan indicating a need for extensive assistance with bathing twice weekly. Resident #17, also with moderate cognitive impairment, reported not having received a shower in over two weeks, contrary to the care plan's directive for showers twice weekly. Similarly, Resident #21, who is cognitively intact but requires maximal assistance with showering, was observed with greasy hair and body odor, having received only one shower in the documented period. Other residents, such as Resident #32, #46, and #47, also exhibited signs of inadequate personal hygiene, with observations noting greasy hair and skin, and residents expressing concerns about the lack of regular showers. Interviews with facility staff, including CNAs, an LPN, the Director of Nursing, and the Administrator, highlighted staffing issues as a contributing factor to the deficiency. Staff acknowledged that showers were not being completed as per policy due to insufficient personnel, with only one shower aide available when two were needed. The Director of Nursing and Administrator noted that showers should be documented in the residents' electronic health records, but there was a discrepancy between the documentation and the actual provision of care, leading to residents not receiving the necessary hygiene assistance.
Failure to Ensure Safe Environment and Medication Self-Administration
Penalty
Summary
The facility staff failed to ensure a safe environment free from accident hazards by not removing chemicals from the dining room during meal service. Observations revealed a container of sanitizing wipes on a dining room table where five residents were seated. Interviews with staff, including a CNA, RN, and Corporate Quality Control staff, confirmed that chemicals should not be stored within residents' reach, especially for those with dementia, as it poses a safety risk. The facility lacked a policy for chemical storage or safety, contributing to this oversight. Additionally, the facility did not assess the safety of self-administration of medications for two residents who had medications within reach in their rooms. One resident, diagnosed with COPD, had an inhaler from home without a self-medication assessment or care plan direction for its use. The resident was unaware of any order for self-administration but used the inhaler as needed. Another resident, diagnosed with Gastrointestinal Reflux Disease, had antacids at the bedside without a self-medication assessment or care plan direction. The resident reported taking antacids for heartburn, provided by staff, without a formal order for self-administration. Interviews with facility staff, including a CMT, RN, and the administrator, revealed a lack of awareness and adherence to the facility's policy on self-administration of medications. Staff were not aware of any residents authorized to keep medications at the bedside, and there was no documentation of assessments or orders for self-administration in the medical records. The facility's policy requires an interdisciplinary team assessment and documentation for residents to self-administer medications, which was not followed in these cases.
Failure to Ensure Appropriate Diagnosis and Duration for Psychotropic Medications
Penalty
Summary
The facility staff failed to ensure that medication regimens were free from unnecessary medications, as evidenced by the lack of appropriate diagnoses for the use of psychotropic medications in three residents. Specifically, Resident #20 was prescribed Clonazepam without a corresponding diagnosis, Resident #32 was prescribed Buspirone without a diagnosis of anxiety, and Resident #45 had an order for Vraylar with a diagnosis simply listed as antipsychotic, which did not correlate with a specific condition. Interviews with various staff members, including a Registered Nurse, Licensed Practical Nurse, Certified Medication Technician, Director of Nursing, and Corporate Quality Assurance representative, revealed a lack of adherence to the policy that requires a diagnosis to match each prescribed medication. Additionally, the facility failed to limit as-needed psychotropic medication orders to 14 days for Resident #60, who had severe cognitive impairment and diagnoses of schizophrenia, anxiety, and depression. The resident's orders for Buspirone and Lorazepam did not include a 14-day stop date, contrary to the facility's policy. Interviews with the Director of Nursing and Corporate Quality Assurance representative confirmed that there should be a 14-day stop date for such medications, and a mock survey had previously identified this issue as a problem with physician orders.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility staff failed to obtain a reason for the use of a urinary catheter for two residents, and did not obtain orders for the catheter size or update a care plan for one resident. Additionally, the staff did not appropriately document catheter care for another resident. The facility's Catheter Care policy, dated September 2021, lacked direction for catheter orders, care planning, documentation, or indication for use. Resident #46 was assessed as cognitively intact and intermittently catheterized, but the care plan was not updated to reflect the change from indwelling to intermittent catheterization. The physician order for this resident did not include an indication of use or size of the catheter. Resident #281 was admitted with an order for an indwelling catheter, but the order did not contain an indication for use. The Treatment Administration Record showed that staff failed to document catheter care on several shifts. Interviews with staff revealed a lack of clarity and consistency in catheter care orders and documentation. The Registered Nurse acknowledged that catheter orders should include specific details and be part of a care plan, while the Corporate Quality Control staff noted that documentation was an issue, partly due to challenges with the electronic health record system. The administrator deferred clinical questions to the nursing staff and mentioned that management staff meet to discuss catheter-related risks and infections.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care per shift. The facility's policy, dated 09/01/21, mandates that staffing information be made readily available in a readable format to residents and visitors at any given time. This information should include the facility name, current date, resident census, and the total and actual hours worked by Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, and Certified Nurse Aides. The policy also requires that the staffing sheet be updated to reflect staff absences due to callouts and illness and that it be posted at the beginning of each shift in a prominent place accessible to residents and visitors. Observations on three consecutive days showed that the staff postings did not include the required information in an easily accessible manner. Interviews revealed a lack of awareness and responsibility for this task. A regional staff member indicated that the night shift nurse was responsible for posting the information, with follow-up by the Human Resource person. However, the administrator acknowledged that the Human Resource position was vacant, and the task had been overlooked. The administrator stated that the posting was done on the day of the interview and would remain their responsibility until a new Human Resource person was hired.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility staff failed to ensure residents were allowed to make choices about aspects of their lives in the facility, specifically regarding their right to smoke. Four residents, who were their own responsible persons, were not allowed to smoke due to an ongoing investigation. The facility's Resident Rights Policy states that residents have the right to self-determination and to make choices about significant aspects of their lives. However, the facility suspended smoking breaks for all residents following an incident where one resident went outside to smoke independently. This decision affected residents with varying levels of cognitive impairment, none of whom exhibited behaviors that would justify such a restriction. Interviews with the residents and staff revealed that the suspension of smoking breaks was a direct response to the incident involving one resident. The Administrator, Director of Nursing, and other staff members confirmed that smoking was put on hold for all residents pending the investigation. Residents were informed of this decision and offered nicotine patches as an alternative. The facility is also considering turning into a non-smoking facility. This action was taken without considering the individual rights and preferences of the residents, leading to a deficiency in promoting and facilitating resident self-determination.
Failure to Develop Comprehensive Care Plans for Residents Who Smoke
Penalty
Summary
Facility staff failed to develop a comprehensive person-centered care plan for residents who smoke cigarettes. The facility's smoking policy requires staff to ask about tobacco use during the admission process and during each quarterly or comprehensive Minimum Data Set (MDS) assessment. However, the facility did not have a policy for the development of comprehensive care plans. Review of the care plans for four residents who smoke showed that none contained interventions for supervision, assessment, or safety risks related to smoking. These residents had varying levels of cognitive impairment and no exhibited behaviors, yet their care plans lacked necessary smoking-related interventions. Interviews with facility staff, including an LPN, the Director of Nursing, the administrator, and the MDS coordinator, revealed a lack of awareness and responsibility regarding the inclusion of smoking in care plans. The MDS coordinator admitted that without a completed smoking assessment, it was difficult to know what interventions to add to the care plans. The Director of Nursing and the administrator both believed that smoking should be included in the care plans and that it was the MDS coordinator's responsibility to ensure this. The deficiency was identified during a survey, highlighting the facility's failure to meet the residents' medical and nursing needs related to smoking.
Failure to Notify Guardian of Abuse Allegation and Injury
Penalty
Summary
Facility staff failed to notify the guardian of a resident in a timely manner regarding an allegation of abuse and an injury of unknown source. The facility's policy requires notifying the resident, family, or representative of any changes in condition, including health deterioration or injuries. The resident involved was assessed as severely cognitively impaired, and the incident was documented in the facility's investigation. However, there was no documentation indicating that the resident's guardian was informed of the situation. Interviews revealed a breakdown in communication among staff members. The administrator assumed the guardian had been notified, but it was not done. RN B claimed to have instructed LPN C to contact the guardian, but LPN C stated they were not given such instructions and only completed a skin assessment and statement. The guardian was eventually informed of the incident several days later, which was not in accordance with the facility's policy or the guardian's preference for timely notification.
Delayed Investigation of Abuse Allegation
Penalty
Summary
The facility staff failed to conduct a thorough investigation following an allegation made by a resident who reported being held down by a staff member. The facility's policy on abuse and neglect mandates an immediate investigation, including interviews with all involved parties, such as the alleged victim, perpetrator, witnesses, and others who might have knowledge of the incident. However, the investigation was delayed, and interviews with potential witnesses, including the resident's roommate and visitors, were not conducted until 11 days after the initial report. The resident involved was assessed as severely cognitively impaired, which may have impacted their ability to recall or articulate the incident. The investigation was initiated after a Certified Nursing Assistant reported a large bruise on the resident's chest to a Registered Nurse. Despite this, the facility administrator misunderstood the requirement for a comprehensive investigation, believing the report to the state was merely informational. This misunderstanding led to a significant delay in gathering crucial information from other residents and potential witnesses.
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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